Global Health Center

Student Blog

Yssra Soliman, MSII:

June 21st, 2014 from Cairo, Egypt.

Today was my first official day of the internship. Between the crazy Ramadan schedule and jet lag, I think I snuck in about two hours of sleep. But still, I woke up feeing excited and just a little bit nervous. I had been told repeatedly that I would “see things here that I’d never see in the US.”

I started my day off at 9:30AM. The physicians were all extremely welcoming and excited to have an American medical student. They were also a bit confused on why I would leave the US to come learn in Egypt. My first assignment was outpatient clinics. Physicians of all specialities are required to cover a certain number of outpatient clinics. The shifts seem to last around 2-3 hours.There are three physicians and three nurses in one room or their offices as they are called. Each physician is given a desk or a bare bed to sit their patient on. Patients from this city and much further governates come to this hospital as it offers free pediatric care. Many times they’ve been referred by doctors in their villages to this well-known university hospital. The young patients and their families are often from the most humble and vulnerable populations due to lack of resources, education, healthcare literacy, etc.

I knew that physicians here practiced an art called “spot diagnosis”. In about two to three minutes, the patient can diagnose, refer or write a script for a patient. The patient and parent walks in, the physician asks what brought them. Often, the parent has some type of scans and lab tests that was done at another facility. The doctor quickly skims over the scans and test results. Then, they ask the parent a few questions about the symptoms. Just after that, the patient is sent on his or her way with a script or referral scratched on the back of a piece of paper.

Back at Einstein, I had completed my intro to clinical medicine course in an ER. I had spent months learning how to get a chief complaint, history of present illness, family history, social history, etc. We spent weeks just practicing how to construct solid HPI. I had interviewed several standardized patients,watched the flaws in my technique on video and discussed how to improve with my preceptor. Building rapport with the patient was key to a successful patient interview. My preceptor reminded us endlessly about the importance of the physical exam. Even more, we had completed several write ups after interviewing our patients and received critical feedback. Suddenly, there was no room in this outpatient clinic for the clinical skills that I had tried so hard to develop during MS1.

Yet, I must admit that I am impressed by how swiftly the physicians think. Many times, the physician will not ask about things like the patient’s age or family history. This is unsettling and worrisome for me especially when a genetic disease is being considered or medication prescribed. But, I am still impressed at how confident they are in their diagnosis.

Here are some of the cases that I saw on day 1:

Pt. A is 2.5 years old. She clenches her hands, sits on here stomach and cries as if “she is giving birth” according to the mother. Her stomach becomes hard as a stone. Pt. A has had these episodes for 9-11 months and it seems to happen more at night. The doctor says this is a psychological event and refers her to their service.

Pt. B is 1.5 years old. He became feverish “a few days ago”. The fever passed; however, since then he cannot walk on his own. He will only stand on his own and void if placed in a tub of water. The mother and sister are understandably worried. The patient starts crying loudly in the clinic. I pulled out a few stickers from my white coat and that seemed to distract him a bit. The physician asked me to place him on the ground and see if he could support himself. He could only stand if we held his hands. When his sister held his hands and moved a little further away, he waddled over to her and climbed into her arms. The physician was ready to refer him but the adjacent physician asked what was going on. When we explained to her the case, she came over and put the young boy onto her patient bed. The two physicians checked his reflexes and decided that the issue could be neurological or autoimmune. They decided to send him to the ER. Later during a night shift, I saw the patient in the wards under observation for 24 hours. I spent a bit of time with him and his family that night before the Fajr (dawn) prayers. I wished there was more I can do than just play with stickers and offer words of support.

After the outpatient clinic, I went to the pediatric ER. A feverish one year old boy was carried in by his mom. Before even touching him, I could feel the heat radiating off his skin. The physician asked his mother to go to the pharmacy and buy 1) a thermometer 2) anything to bring his temperature down before coming back to the ER. I knew that here patients buy their own medications, carry around their own blood bags, carry samples, etc. But, I was really confused on why patients were sent to buy their own thermometers in an ER. The physician explained that it was due to sanitation reasons since they can’t use the same thermometer for several patients. I asked why they didn’t use the plastic covers we often use in American healthcare settings. The doctor replied “that type of technology hasn’t reached us yet.”

I probably saw over fifty patients on my first day alone. These cases offer just a snapshot of a typical day at one of the most prestigious medical universities in the region. Throughout the day, I couldn’t help but feel lucky to be both a patient and medical student in the US. I know that the American healthcare system is far from perfect and even broken in some areas. I am often frustrated by healthcare disparities, language barriers, lack of universal access to healthcare, etc. But I always took our latex gloves, sanitizer dispensers and covered hospital beds for granted. In the US, patient privacy is an unnegotiable right guaranteed to all our patients. Here, several patients can be examined right next to each other on a desk with numerous white coated interns, residents, and attendings peering curiously over. Lab results are loudly called across the ER.

I walked out of my first day on the job feeling exhausted, frustrated, blessed but still somehow strangely positive. One thing really stuck to me. A patient came up to the ER desk and said “this is the cleanest hospital that I have ever been in, everyone is praying for you doctors.” She sent chills down my spine as I imagined her journey.

I am waiting to see where the next few weeks take me.

June 30, 2015
from Egypt

Doctor #1

I have been at my
internship for over a week.I’ve been in outpatient clinics, hepatology clinics,

GI clinics, the ER
and ICU among other things
so far. I have gotten to know
patients, physicians, residents, interns,
nurses and staff. This experience
has been a huge privilege check for me. I have been fortunate to live
most of my life on the east coast and experience some of the most
world-renowned medical centers. At the same
time, I have spent lots of time back home in “low- income nursing homes”,
volunteering at free clinics, volunteering at bare-bones
medical facilities, etc. But still, none of
this can compare to what I have experienced during my internship. This
experience has been the biggest privilege check for me. I think the first few days,
it was very easy see the gaps in healthcare here. It was easy to see the lack of training, stoic attitudes, etc. But the more
9-4 shifts I spent, the more I
could see that it was way
more complex. There are huge flaws in the entire
system. But today, I want to reflect
onn the good physicians who have truly
impacted me.

I met Dr. J
during my second day in the ER. The pediatrics hospital
is actually split into two different hospitals
that are across the street
from one another. The ER rotates between the two buildings every other day. This was
my first day in the second hospital and I have found it to be cccc consistently more hectic and stressful. I was actually assigned
a different doctor for the day
but Dr. J was covering for her. The other doctor had been sick for a several days with a persistent fever. Ironically, Dr. J
himself was very sick and even
speaking was painful for him. Yet, he
was in charge of the ER and the ICU for the day. He also had several “administrative duties”.
I followed Dr. J as he saw every single patient in the ER and the ICU after the resident physicians had already seen them. Many times a resident had misdiagnosed a
patient or had not ordered the correct set of labs. But Dr. J
was not harsh or punitive. Instead, he took
the time to explain
the full case to us. He re-examined each patient and reassessed their condition. He guided the residents, interns
and I through the full
differential and treatment plan. Even more importantly, he
took the time to explain the patient’s conditions to the worried parent. This is something that was
hugely neglected here. Most parents try to catch a few
things as the medical team stands over their child’s
bed and discusses the case. However, medicine is taught in English here and, thus, the medical
team mostly converses in English. Many of
our patients cannot read and write Arabic, let alone speak English.

With Dr. J, we
discussed several cases of hepatosplenomegaly, anemia
caused by worms and G6PD. I walked out of the ER
happy that I had learned a lot and
seen several cases. But, I was
also content because I knew that the patients and families in that ER were
going to be alright t!oday. Dr. J
was going to make sure their children received the best care
possible. The next morning, I reported to my
outpatient clinic and found Dr. J again.
His voice had begun to come back but it was
evident that he was still ill. As usual, we saw an incredible amount of patients. But Dr. J
spent as much time as he needed with each and every single one of
them. We ended up finishing our clinic an hour and
a half after the other doctors.
As we were leaving, another patient
appeared in the waiting area.
We put our stuff down
and listened to his chest, palpated his abdomen, and wrote him a script right there
and then. Dr. J
wanted to send eeveryone home
satisfied that day and he did.

July 2, 2015
from Egypt

Doctor #2

Aside from ER shifts, this week, I rotated in hepatology, GI and tropical medicine clinics. They
were an incredible learning experience for many
reasons. But today, there
was one physician that really
made a difference. For the past ten days,
I have seen the incredible amount of stress that doctors
are under at this institution.

Here is a quick summary
of how one becomes a doctor. During
high school, students take standardized exams which
determine your major and university. One must place
in the 99th percentile to attend medical school. There are only about 10 medical schools in the country
and only degrees from the top three are truly recognized in the region
and abroad. The students study medicine in great depth in those
six years. For example,
all of fifth year is devoted to pediatrics and
reproductive medicine. However, there
is nothing equivalent to the American Step 1, 2 and 3 to integrate what they’ve learned.After six years of medical
coursework, students graduate and enter into their “internships.” This internship year is very similar to the American
MS3 where students rotate in different specialities. However, here,
the house officers work thirty hour weeks where they simply run labs, transport patients and submit requests for bags of plasma. They refer to these as “dirty duties.” There is no shelf exam, there are no grades, there is little to check what medical knowledge the house
officers have learned. After
the house officer year, they then progress
to another year where they train at a
general medical center. Only after that can they
apply for residency based on
their class rankings. Only the top 200/1500 will even get into residencies
at their institution. The others
will have to pay for their residencies or settle for general
residencies in less established places. After residency
one submits a thesis, then becomes
a assistant professor, and
finally a professor. Only when
one is a professor will he have
earned his MD degree. The life of the average
40 year old “professor” physician includes mandatory outpatient and
specialized clinics at this university hospital, mandatory teaching at the medical institution, mandatory
shifts in the ER and finally having a personal office to make
any type of income. Most physicians here are middle class and some ccannot
even afford medical care for their own children.

The purpose of this lengthy side note is to show the pressure that doctors face here.
Thus, it is very easy for doctors to become
jaded, unprofessional, dismissive, etc. This is why Dr. H really stuck out to me. Dr. H
is the head of the pediatric hepatology. She is a strong, independent, intelligent woman who demands respect from even
the most veteran physicians. When I first met Dr. H, she
was describing to a father that his
son’s hepatomegaly was similar to hanging your laundry a bit unevenly
on the clothes line,
so that you see the edge on one side sticking out. I was
instantly interested by her ways. I had seen to many parents leave this hospital
without even knowing what their
child was diagnosed with. But Dr. H met
this father at a
level that made sense to him.

Within minutes
of meeting Dr. H, she
had me measuring patients, plotting their
weight percentile, percussing
livers, palpating spleens,
etc. She was a force to be
reckoned with. The hepatology clinic is set up with three desks making a U shape and about 6 senior physicians seeing patients simultaneously. If she saw any of her senior physicians cutting
any corners with their patients, she was not shy to call them out in
front of the entire clinic.
When there was scheduling conflict with the residents, a resident tried to take on
two back to back 24 hour shifts. Dr. H refused and said “I don’t care if
the resident collapses. He can collapse for all
I care. But I need him to have enough health to take care of
our patients, nothing more.”
Later in the week, I
attended staff rounds with the senior
physicians and residents. Our medical team of about 15 people rounded on the entire
ward. We then went upstairs where a physician presented on “acute on chronic liver failure.” Dr. H
caught a senior physician on his
phone, walked over, and
took it away from him. After the presentation was over, she assigned specific cases to physicians because she wanted to implement the techniques described in this study to her clinic starting the following day. I saw
Dr.
H two days later and she asked me about my previous day. I described how I attended
an outpatient clinic, then a
GI clinic, then rounded on
hepatology patients before ending the day in the ER. She asked me if I am exhausted when I
get home and I nodded my head yes. She replied “good, I want you to
go home everyday so exhausted you
cannot see in front of you because then you know you’ve done all that
you can.”

I admit that her methods are unique. But I have
never seen a physician so committed to their patients. Dr. H
will move mountains to make sure that her patients are
receiving the best care possible. With a single phone
call, she can have an MRI in her hands, something that would take months to even
get an appointment for since
there is a handful of machines
available in the entire country. Also, in a conservative society where women
often cannot even purchase groceries alone,
Dr. H is a revolution. She
is being paid very little for her time
at this hospital. But she has shown me that even in the worst of situations, medicine is still all
about the patient. She is the definition of “where
there’s a will, there’s a
way.”

July 5, 2015
from Egypt

A Week of Hepatology, Gastroenterology and Tropical
Medicine

I spent my second week
at the hospital rotating through
these services. Although
I still find myself frustrated at the lack of
resources or proper training, there is a bit
of a silver lining. These services are run by extremely dedicated
physicians who do whatever they can to
make ends meet for their
patients. Here are some
scenarios from this week:

1) Pt YA is a 28 month old patient. He
presented to the hepatology clinic with abdomen distention, pallor, jaundice
and doll-like facies. His mother claims that he has been “sick since he was born”. For the past six
months he loses consciousness and
has episodes of cold sweats, the classic
description of fasting
hypoglycemic spells. His
history is also positive for previous convulsions, hemoptysis and melena in the past six months. The physician
explained to me that his untreated hypoglycemia has caused a permanent epileptic focus. Pt YA is
now on anti-convulsant treatments for the syncope attacks. The physician also
concluded the pt had delayed motor development. The next step was to
order a CT scan to rule out
associated myopathy. Furthermore, the patient had positive palmar erythema, a
sign of liver failure. We
palpated his abdomen and found the liver
to be RT 8cm, MCL 7cm
and LT 10CM. In other words, his liver was enlarged We ordered a myriad of lab tests to check his CBC, liver profile, lactate, glucose, uric acid, etc. Unfortunately, not all of
these lab tests are available at the pediatric hospital and the
family will have to go to
different outside
labs to finish the exams.
An ultrasound revealed the liver to
be enlarged and bright without focal
lesions. The size of
his spleen was on the upper
limit of normal for his age
group. This patient most likely has a glycogen storage disease. The patient and his mother were sent to complete
the labs and come back to the clinic later in the week.

2) Pt SM is a five year old bilharizia patient. Bilharizia or schistosomes is a chronic, endemic disease in this region. In fact, the disease
is often associated with the late Abdel
Halim Hafez, a legendary singer in
the Middle East who passed away due to liver complications of his
disease. Bilharzia is caused by parasitic worms
spread via contaminated water. This patient
had been diagnosed only four months ago. His
CT showed a urinary bladder with diffuses nodular dense thickening and intravescial soft tissue masses,
hallmark findings of the disease.
This family is from
a remote village where clean
water is a luxury afforded
by few. It is frustrating that many
of our patients become ill because
of things we often take granted
in the West such
as pollution, llack of clean water, and poor
sanitation.

3) Pt AM presented to the hepatology clinic with diagnosed
Criggler-Najjar disease, a disease Ithought I would only ever see in class. Patients
with this disease have a deficiency of conjugation
enzymes and have very high levels of unconjugated bilirubin. The only available
treatment is intensive phototherapy. However, when
the child grows up, it becomes
difficult to do sessions of phototherapy lasting
12-14 hours a day. Thus,
the child will become a
candidate for liver transplant. The patient’s father was set
to be a liver donor for his son.
However, the situation became complicated when the
father was found to have
a bifurcated portal vein. Furthermore, the patient’s mother has an incompatible blood type and cannot be a donor. The
rules of the hospital are that only the
parents or first degree relatives are eligible to be
donors for their children. This puts many patients in difficult situations especially if the health of the
parents is also poor. The plan for
this family is to
reevaluate the father
to see if there
is anyway that the transplant surgery can take place. Otherwise, they will have to seek out
close relatives ass possible
donors.

4) Pt DC presented with tyrosinemia with hepatorenal manifestations. These patients cannot convert amino acid tyrosine into dopamine. Instead,
tyrosine is degraded to toxic
metabolites that can build up
and cause damage to the kidney and liver. In fact,
it can put the patient at risk
for hepatocellular carcinoma. In developed
countries, the treatment is a drug
that causes tyrosine degradation to a non-toxic metabolite. Unfortunately, this drug
is not available here and costs 20,000
EGP a month if imported from other countries. This is more than most of our patient’s families make in a year. Thus, our patient is a candidate for liver transplant, the only t!reatment option
available.

5) Pt RA is
a five year old female with Alagille syndrome and growth hormone deficiency. Alagille is an autosomal dominant genetic
disorder with systemic manifestations often affecting
the liver. This
beautiful young girl had the facies
typical of Alagille, deep receded eyes, a
straight nose, prominent chin and broad forehead. This was
the first time I had heard of the disease but it wasn’t the pathophysiology that made
this case stick out. The mother
explained that her daughter’s father
was one of the wealthiest in their village. However, the father had spoken to several physicians who had
said that the girl’s prognosis was
poor and would not make it to her
teens. The father told the mother that “it is not
worth throwing our money in the ground” about his
daughter’s treatment. Immediately, the physician called over Dr. H, the head
of the department. They sat down with the mother and explained that we can never say for sure
what will happen to the patient.
Dr. H said “if I leave this hospital right now, I can
get into a fatal car accident but this does not
mean I should stop living.”
Dr. H and the physician
told the mother that
it was her responsibility to make
sure that her daughter received all the care she needed and that they would help her. They followed
their promise and set up an appointment with the best cardiologist and endocrinologist at the hospital for pt RA. They also found all the medications that she needed and confirmed another
appointment for her at their clinic.

July 10, 2015
from Egypt

Medicine,
Education and Buttons

The circle of poverty is more like
a whirlpool for our patients. Last week
a physician said to me “look at how the patient’s overalls have been sewed together without
a button, this is because even a button is too
expensive for some of our patients.” The circle gets wider when one’s education and
health gets sucked into it. For this generation of children, a good education might be the only
way to climb out of the circle of poverty. But what are they
to do when their health sstops them from attending school?

“Yellowness”

A 9 year old female patient came to
our hepatology clinic with her father. In her history, she explained that 9 months ago, she
had become rather jaundiced. Labs done in her far-out town showed elevated liver enzymes. However, doctors
were not able to conclude what the underlying pathology was. A recent liver biopsy showed patterns of chronic
hepatitis with moderate fibrosis. The physician at the clinic
ordered a full liver panel, CBC and ultrasound a among other things investigate what could
be making the patient ill. When she presented in to our clinic, the sclera
of her eyes was clear and did not appear jaundiced. However, this “yellowness” is what had caused her to be dismissed from school
in September and has not been allowed to return since. The patient should have completed the fourth grade this year. There are no rules here that require children to stay in
school until they are 18. In the states, if a
child skips school to go to the mall, a local police officer may very well drive him to school and his parents could receive a hefty fine.
When I volunteered at a childrens’ hospital, a teachers aide would deliver the student’s homework
to the hospital and tutors would hhelp
the children stay caught
up on their course work. None of
these social services exist here. I became very frustrated and
upset for our patient. The physician explained that there
is a common misconception that anyone with jaundice is contagious. This is ironic especially in a country with endemic
rates of Hepatitis A virus.
HAV is transmitted via
the fecal-oral route, mostly
via unwashed produce and contaminated water. Poor
sanitation and personal hygiene here
probably contribute to the high
prevalence. However, any
of us here are at risk for contracting HAV at anytime, we all drink water and eat fruits and vegetables. Also, the physician explained that the period
of contagious activity is only
about 10-15 days, not an
entire school year. Before leaving the states, I was vaccinated against HAV. Unfortunately, this vaccine is still nnot required even
with the huge health burden
that it causes to residents of this country. Our patient
will most likely not be allowed back to school until we
figure out her disease and can give the school a signed note saying that she is no way contagious. But what if the principal
of the school is still fearful
of the “yellowness”? She may still not be taken
back to school. What if
the lengthy trip from her town
to our city becomes too much for her
parents? She may still not be taken back to school.

“Alpha One”

I met patients M and H during my first nephrology clinic. They are both brothers
ages 9 and 5. The older brother, patent M, had
been dealing with Nephronophthisis for years. His disease went undiagnosed for a long time. At a young age, he suffered multiple
recurrent fractures and had fragile bones. It took several
different doctors to finally diagnose him with Nephronophthisis, a primarily renal disease not
orthopedic as was once thought. This is
a genetic disease where there is progressive destruction of both kidneys.
The disease is marked by
polyuria and polydypsia. Patient M dealt
with both of these things
as well as incontinence. He
could no longer walk at all and was
quickly approaching end stage renal
disease. He was going to become a candidate for liver
transplant. All of these
details were discussed in the stuffy office
with both boys listening. The younger brother, patient H, had
not yet shown full clinical
signs of the disease. However, the doctors
were monitoring him as they expected
him to follow his brothers course.

However, all
of this is besides what brought the family into the clinic today. They were here because they needed
alpha-1-hydroxylase that they simply could not afford. A strip of the
medication costs 40 EGP, simply not sustainable for the family. Both boys were deficient in this enzyme and that put them at risk
for more fractures. This enzyme
is what produces active Vitamin D
in the body. Their mother
was divorced and has several personal health problems to the point where bringing her sons to the hospital was a feat. The older son cannot walk on his own and was carried around by
their neighbor, a 15 year old boy. All
children in this country receive health insurance as long as they are in school. However, the mother’s health
problems prevented her from being able to take her children to school everyday. Thus, they do
not qualify for health
insurance. The only other option is to have three physicians sign off on a document that states that indeed these children should be covered by the national health insurance due to outstanding conditions. The physician
finished the paper work for the mother and her sons immediately. The head of
the department of nephrology
even gave them enough Alpha-one drops to last until the government processed their paperwork. I am thrilled that they were able to finish their paperwork immediately. But what good
does insurance do if the mother
cannot bring her children to the hospital most of the time? Even more, the mother claims that they do not have any family to help them. Who will donate their
kidneys to these children when the time comes? The mother
cannot because of her own health problems. I don’t
think they can afford
the hefty price tag that comes with private hospitals that allow
transplant donors to be non- relatives. What good does
insurance do if the children will not be able to get an education? These alpha-one drops seemed like a small
victory at the time but I found
myself entertaining more
cynical thoughts throughout the day. I found
myself frustrated at the complete
lack of social services in the country. There aren’t
enough Alpha-one drops in the world to
fix this whirlpool, no
tsunami, of poverty.

I can’t believe that we are on our way home! Or maybe we are
leaving home, I guess it depends on how you look at it. After two months in
Kisoro, it definitely felt like home to me. But the end of our time went very
well. Since I last wrote it has been two weeks, but the last several days were
all report-writing and preparing our final presentation. The last work days
were pretty good though.

On Thursday, July 24th, we had our great Thursday
shadowing day at the chronic care clinic. I got to work with Nate, which was
really wonderful since he was going to be leaving on the coming Saturday. Most
of the patients were pretty straightforward, but it was really nice to see the
way he worked with patients. Even when the medicine itself isn’t too
complicated and I don’t have too much to learn from the case itself, watching
good doctors care for patients is always educational. We had one very
interesting patient though, a man who was in acute alcohol withdrawal and had
severe abdominal swelling. I felt so badly for him, he was just shaking all
over. Examining his abdominal swelling was a great review of the abdominal
physical exam that we had learned last year. Since he had so much swelling,
which is called ascites when it is due to fluid, Nate was able to figure out
how much fluid was in his abdomen by listening to the different sounds he heard
while percussing (a physical exam technique that is a specific method of
tapping) on his stomach. By using this technique with the patient in different
positions, we were able to find a kind of fill line where we knew that we was
full of fluid. After CCC we went to beans place as always, and it was delicious
as always. Then market day! It was our last time down to the big market, which
was kind of sad, but it was fun. We completed most of the shopping we had to do
for the rest of the trip that afternoon.

On Friday we had a nutrition screening day, which was kind
of fun because it was back to our old routine that we had started with in the
beginning of the trip. That went well, and we saw over 100 kids, which is
always great. Very few who were malnourished, so that was even better. After
screening we went to the café and worked on some of our reports until the
evening. Since Friday was Nate’s last night, we went out for a great big fancy
dinner at the hotel nearby, called Traveler’s Rest. It was one of the most
spectacular meals I have ever had, and it was wonderful to be with our whole
crew one more time before Nate returned home. All of the other students, the
residents, and Nori are just amazing people, and every conversation I have had
with them all summer has taught me something.

On Saturday I had my last day out with Jerome. It was a good
day, but it was short and kind of chilly because it was misty and cloudy. But
time with Jerome is always time well-spent, and I’m glad I got to have that
last day with him. When I got home from that, which was early, I just went to
Coffee Pot again to work more on reports. We took a bit of a break in the
middle of the afternoon because Nori came by there to work too, and we had
another lovely and highly educational conversation with him. We worked most of
the day, until the evening when we had movie night with everyone. It was my
first Planet Earth experience, and it was pretty amazing. Definitely going to
have to see the rest of the series once I get home.

Sunday was a bit of a lost day, I wasn’t feeling very well
so I just rested a lot. On Monday I had nutrition screening again, and it was
an exciting day because my awesome translator, Julius, got his college
acceptance notification! The screening day was like usual, and Hannah’s day
doing nutrition follow up was good too. In the evening we went for a hike of
Hospital Hill as we often do, and that was a really beautiful one. It was
extremely clear weather and close to sunset, so the views were even better than
usual. Definitely one of the moments when I was wondering how it would ever be
possible for me to leave Kisoro.

On Tuesday, my scheduled activities got canceled because of
conflicts with the VHW. So I decided to try and take advantage of the
opportunity and go to the hospital to see some more of what it’s like to work
there. I spent most of the day shadowing Adam, an awesome nurse practitioner
who has been to Kisoro multiple times, and learned more than I would have
thought possible for just one day. We saw a patient with HIV, a patient who had
a stroke, a young woman who probably had a bleed somewhere in her intestines, and
a woman with severe diarrhea. It was a huge range, and really interesting to
see how a good history and physical exam can be used to learn so much even
without as much technology as we have in the US. In the early afternoon we took
a break and went to beans place, of course, and then I met up with Hannah
because she was back from her day in the community. We had a planning meeting
with Valence, who helps lead our focus groups, to plan our final focus group
session. We decided that marriage would be a good kind of all-encompassing
topic to use for the last day because it would let us touch on several of the
other topics we had covered. We came up with some great discussion questions,
and we wrote and translated a survey that we could use to get some feedback
from the group members about their experience in the focus groups. Then we went
to hike Hospital Hill again, but this time with Emma, Adam, Sean, one of the
translators, Angel, and one of the residents who had just arrived for the month
of August, Mai. That was the best hike of the whole trip. It was an even more
beautiful day than the day before, and having so many people with us was
wonderful. We had a great time, and I am glad I got to be there when so many
people were seeing those things for the first time. Unfortunately, while we
were eating dinner after getting home, I got a phone call that my focus group
would not be meeting the following day. I was so disappointed because that was
going to be my last opportunity to go to Nyagihenge and work with the group,
but there was nothing I could do about it. I had a great focus group experience
overall, but there were definitely a lot of frustrations involved. Losing the
last session was really sad. I hope that some of our original goals for the
group were accomplished, and that some of the men and women started to think
and talk about things more openly with their partners. I think that next time
students have focus groups it will have to be a little bit more organized so
that attendance is more consistent and we are able to really work with the same
people to make progress over time.

Since I didn’t go out to the focus group on Wednesday, I
worked on writing my reports instead. In the afternoon after Hannah got home we
made preparations for Wanda’s birthday! We baked oatmeal chocolate chip cookies
on the stove, which I had no idea was even possible. We also made brownies and
decorated the yard so that it would look awesome when she got home. The
celebrations were all wonderful, and many of our Ugandan friends came. We had
great food and a bonfire, where we played charades. It was all magical and
wonderful, generally an awesome night.

Thursday was a CCC day again, and I got to shadow one of the
residents who just arrived for August, Jon. He was really wonderful to work
with also, of course, and it was a nice day. We didn’t have any crazy patients,
but I still learned a lot as I have every time. After our usual beans, we just
got down to work again. By the end of the summer 8 reports were expected of us,
so we spent a lot of time writing in the last week.

Friday we had our last day of nutrition follow-up surveys.
That was just hard to believe, we spent so much time working on this project
and to have the data collection come to an end was really crazy. But the day
went well, and we were able to see all of the children that the VHWs knew about
from the nutrition program. The two VHWs we were working with were particularly
wonderful, so it was a really nice day. We really haven’t taken enough pictures
of our work or with the VHWs, but we remembered to take a picture with them
before we left. That was nice, and they were really excited about it. But I
always hate having to say goodbye to people. Everyone in Kisoro is so
wonderful, and they all are genuinely sad to see us leave, saying goodbye is
just brutal. Thankfully I know that it won’t be goodbye forever though. After
all the amazing experiences and how much I have learned this summer, I know
I’ll be back again 4th year. But these two years are going to be a
long wait to get back to all of the great partners and friends we have worked
with and lived with.

The afternoon and evening were again filled with writing.

Saturday was supposed to be our last day in the community.
But just as I had bad luck earlier in the week, when we got out to the village where
we had planned to do one more nutrition screening day, we found that the VHW
had just given birth and hadn’t been able to organize a screening. So we just
had to turn around and head home, which was kind of sad. Friday was a great
last day, but it would have been nice to be prepared to let go of our work at
that time. The community in Kisoro has come to mean a lot to me, and not having
the kind of complete ending that I wanted was hard. I wasn’t ready for Friday
to have been the last day, I just wasn’t in the mindset. But one day more or
less doesn’t take away anything from the amazing summer I had. I hope that our
work had one tiny fraction of the impact on the community that the community
had on me.

Saturday through Tuesday were spent writing reports and
preparing a presentation for the administrators at KDH. All of that went well,
and as much as sitting and staring at computer screens all day and night was
not nearly as fun as working in the villages, it felt good to see all of our
work come together and to be able to share what we had done with others. We
were able to see that what we had been doing was going to be useful, and that
all of our work and our findings will contribute to the future of great
programs in Kisoro. We wrote a reports about each oft the following projects,
and also presented all of our findings and suggestions for improvements to the
team at KDH: follow-up with Jerome, nutrition screening, VHW interviews, focus
groups, targeted surveys in the community about chronic disease, family
planning, and home vs hospital delivery, and the nutrition follow-up project.
If you’re at all interested in any of the projects we did, I would be happy to
share the report about that topic with you. It was a lot of work to make these
projects happen and a lot of work to create meaningful reports, but it was work
that we know we can be proud of. And we know that it is going to be used right
away to have real impacts on people’s lives.

On Wednesday we mostly spent the day packing and preparing
to leave. In the afternoon we gave our presentation to a much larger group than
we had expected to see. To our relief, it went well and everyone was really
happy with the work that we had done. The end of the presentation was sad
though, because it meant that our work in Kisoro had officially come to a
close. Saying goodbye to everyone was difficult, but at least we know that it’s
not goodbye forever. We will be back soon. In the evening on Wednesday we had
an awesome taco night with everyone and some of our Ugandan friends, and we
roasted marshmallows around a bonfire. Helping Ugandans make their first
s’mores was definitely an awesome moment.

I stayed up way too late because I didn’t want the night to
end, knowing that when I woke up I would have to leave. I can’t believe I ever
considered doing something else for the summer. There is no better place I
could have been and no better way I could have been spending my time. I have
learned about many medical topics, about community health, about medicine in
the developing world, about the wonderful culture of the people in Kisoro, but
more than anything I have learned a lot about myself and what I want my future
to look like. I am not the same person who left New York 9 weeks ago, and my
plans for my career in medicine in this world are definitely not the same
either. I may not know any more certainly what field I will enter, but I know
that the world is a lot bigger than I ever imagined and that there are a lot
more places worth going to and working in than I have ever considered. I don’t
know where the future will take me, but I know that leaving Kisoro this summer
is not the end of anything. This is just the beginning.

As we wait for the last leg of our journey home to begin
here in Brussels airport, I can’t help but feel a little apprehensive about
returning to a world that is now so different than the normal I have grown
accustomed to over these weeks. But I know that I am coming back to amazing
people who will make the transition significantly easier just by the virtue of
their presence in my life. Thank you all for reading my ramblings all summer,
and thank you for all of your help and support throughout this adventure and
all those previously. I wouldn’t have been able to do this without you. Here’s
to whatever comes next!

July 24, 2014. Hannah in Kisoro, Uganda

Today I conducted nutrition follow-up surveys in one of the villages. My coworker/translator and I rode a
motorcycle to the village (he drove, I sat on the back and tried not to fall
off), with our giant height-measuring board tied to the back. Immediately into
the ride, the bike got a flat tire, but fortunately we only had to push the
bike a little ways to the nearest repair shop (he pushed, I carried the
helmets). Only a little delayed,
we finished the ride to the village, which was a bumpy one, and partly across a
huge and very rocky field of grass. We had to swerve a lot to avoid all the
volcanic rocks and cows. Many cows. Some goats, too. When we got there, I was
relieved to find that the VHW (village health worker) had mobilized a good number
of women and children for us to interview. We first took weight, height and
MUAC on all the children, some being more difficult than others. We have to lay
them down flat on a board to get their height, which is easier said than done
when the child is screaming and squirming around. Weight is especially hard to
get when the child is screaming and moving up and down, because the needle on
the scale bounces up and down along with the child when the child won’t stay
still. You have to catch their weight on the split second between screams when
the child isn’t moving. We managed
to measure all the children eventually, and moved on to interviewing
mothers. In the meantime, the tire went flat for a second time and had to be repaired again.

On our survey we ask how
many children they have, many today had 8 or 9. I usually ask if they’re planning
on having any more, and today most said no, but out of the 12 women, only 1 was
using family planning. Many were interested in it, or thinking about it, so I
hope that they will follow up on our conversations and visit the women’s clinic
soon, or at least discuss their options with their VHW. I’m now realizing more and more how
important family planning is for the health of young children, not just mothers.
If a mother has a child who is still breastfeeding and gets pregnant again, she
is likely to stop

breastfeeding, which puts that child at risk for
malnutrition. Many of the mothers we interviewed stopped breastfeeding their
children before 2 years because they were pregnant again, some of them thinking
that when they’re pregnant, the breast milk is making the children sick. I
tried to emphasize the importance of breastfeeding to two years, I hope the
message got through.

One mother
today had an 8-year-old child with epilepsy who had never been seen by a
doctor. We’re going to try to get
her evaluated soon when the chronic disease team visits her village. In another interview with a grandmother, she revealed that she had gone to visit her daughter and found
her grandson malnourished, so had taken him into her own care. This reminds me of an amazing nurse
that I met here who had a young patient with diabetes and negligent parents, and
took the child into her own care as well.
Now the child is doing much better. I am again and again amazed at how kind people are in Kisoro,
even small acts of kindness really add up and mean something.

Yesterday I interviewed a mother who had a young daughter, let’s
call her Molly (not her real name), who was severely stunted, and had already
been in the nutrition program for 3 years but hadn’t grown properly. They told
me how they had gone to another hospital far away and were told that Molly had
a “hole in her heart”. The
hospital told Molly’s family that they would call to follow up. Molly’s family
went home, they never called. That was more than two years ago. I want to find out if she’s a candidate
for surgery and then go from there. They don’t have the capacity for that kind
of surgery here; I’m told people can go to Kenya or even India for heart
surgeries. I’m also told a surgery
like that may cost around $500. The price of an Iphone. Puts things in
perspective.

July 23, 2014. Cynthia in Kisoro, Uganda

I can’t believe that my time here
is almost up. Only two more weeks, and only 1.5 weeks left going out to the
community. This summer has absolutely flown by. I feel like each day has gotten
busier and busier, but I am extremely grateful for the kind of experience I
have had here and for the knowledge that I have spent my time well. Since I
wrote last Wednesday, things here have been good. Wednesday afternoon after our
focus groups we spent a lot of time working on data entry and analysis. Things
with that are going pretty well, but Hannah and I are not very experienced with
using Excel so we are a little stumped with what to do now that we have finally
entered all of our data. I think we are making progress on things though.

Here are two photos: one from our Wednesday focus group and one from
nutrition follow-up survey days.

Thursday
we got to shadow in the Chronic Care Clinic, and it was really awesome. Working
with the residents is wonderful. They know so much and are great teachers. I
worked with Sean on Thursday, and he taught me a lot about different kinds of
heart failure, depression, and complications of diabetes, among other things.
We reviewed a lot about physical exam technique, and I got to practice that a
lot. I also appreciate how wonderful patients are about working with students
here. Not that they aren’t great at home too, but I always appreciate when
patients let us take the extra time to learn with them. We also got to see two
special cases that Nori pulled us all out for. The first one was a patient with
rheumatic heart disease, which is sadly very common here. There are a huge
number of young people who have completely failing valves, and can’t afford the
flight to India that they would need to get the necessary surgery. The woman we
saw last week had two very particular and distinct heart murmurs that Nori
wanted us all to hear and learn about. It was a really unique opportunity, and
definitely a lot more helpful than listening to the recorded heart sounds that
we get at school. I found the teaching case especially interesting because it
had to do with something that we had actually learned about in class! There was
a man with pellagra, a vitamin B deficiency that presents with a specific skin
rash. Elena had diagnosed it herself, which was super awesome, and it was cool
to see something in real life that we had seen in books.

After CCC we had the customary
lunch at beans place, and then set off to accomplish a lot of errands, Thursday
being market day. It was all a great success, and we returned home feeling very
accomplished. We did a little bit more work before starting to work on dinner,
which was a fantastic group taco night! We all ate together outside and turned
off the lights so we could see the stars better. It was an utterly beautiful
night, and we could even see the Milky Way. It definitely ranks highly on my
list of greatest days ever. A day full of learning, tacos, great people, jazz
music, and stargazing is just about as good as it gets.

Friday was a big adventure. I went
out with Jerome for patient follow-up and to check on the TB registries at
health centers to make sure that all Kisoro Hospital patients are getting their
TB treatment on schedule. It was all going well and seemed like a pretty
average day, apart from a marvelous sighting of a huge group of Ugandan cranes,
which are seriously beautiful and not common enough here. Then around 12:30 or
1 Jerome got a phone call from Sean at the hospital. He told us that a patient
had escaped from the hospital, and that he was suspected of having
multi-drug-resistant tuberculosis (MDR TB). A patient like that walking around
town is not a minor concern, but can be a public health disaster. Since TB is
airborne and highly contagious, we even keep TB patients in an isolated room at
the hospital. A patient with TB that is not responsive to the normal drug
regimen is particularly disturbing, and spread of such a disease could have a
huge cost. Given these concerns, Jerome and I stopped the rest of our work and
set out to find the missing patient. We found out what village he lived in, and
made the long, bumpy drive out there. When we got nearby, we started asking
people if they knew the man and if he was around. Fortunately, we found some of
his grandchildren fairly early in our search. They told us that he had come
home late the night before and was at home resting.

They led us to the family home, and
sure enough we found the patient lying on a mattress in the yard. There were
many family members around: his children and grandchildren in a big crowd. We
came and sat down and started to talk to him about what had happened and why he
left the hospital when he was so sick. He told us that he left because no one
was paying attention to him or taking care of him at KDH. I was surprised to
hear this, since I know the people caring for him and know that they do not
ignore their patients. We asked him to explain further, and he told us a story
that made both Jerome and me utterly furious. He said that the previous week he
had been told he needed a chest x-ray, so he went to the imaging center to have
it done. When he got there, the imaging technician told him that she wouldn’t
do it for him now, and to come back on Tuesday. When he returned on Tuesday,
she again told him that she wouldn’t do it. He got upset and told her she had
given him an appointment for Tuesday, so when would she do the x-ray. She told
him, “When I feel like it, I’ll come and find you and tell you.”He waited another day or so, but when
she still didn’t come to do the x-ray he got very frustrated and decided to
leave the hospital. I kind of understood why he would want to leave, especially
because the progress of his care was halted until that x-ray could be done.
Literally nothing was happening, and he was being told almost directly that he
wasn’t cared about.

Jerome and I were both extremely
upset by this story, because this is just one more in a series of issues caused
by the same x-ray technician. The entire week she had been causing major
trouble, and had decided simply not to work at all for several days. That was a
pretty big problem at KDH, because there is a lot less technology than in the
states, and one of the few diagnostic tools that we have here is the ability to
do some basic imaging. This woman is the only tech, and if she decides not to
work, there is no imaging. The toll of her laziness and selfishness (which is well-known
by all the hospital staff) was mounting rapidly, and the fact that a community
was exposed to potential MDR TB now because of her was the last straw for me
and Jerome. I am surprised that our anger wasn’t visible as a great cloud in
the air around us. I cannot comprehend a person who knows that people’s lives
depend on her job regularly refusing to do that job. Why such a person would
ever enter a healthcare field is beyond my comprehension. I cannot understand
how she can live like that, knowingly denying people potentially life-saving
care for no other reason than because she doesn’t feel like it. Such behavior
is nearly equal to murder in my mind. It is highly unfortunate that the system
here is setup such that hospital employees get government salaries regardless
of how much work they do, and there really isn’t a way to keep them
accountable. If someone decided not to come to work for a week in the US, that
person would be fired immediately. But this woman has not been and will not be
fired, despite her recurrent neglect of her job and the patients depending on
her work.

Jerome and I spent a good amount of
time trying to make our patient understand that the x-ray technician is not
representative of everyone working at KDH. His doctors really care about
helping to make him better, and wasn’t the fact that we had come to find him
proof that people were really concerned about him? We also talked to him about
the risk to his family if he stayed home. With so many small children running
around and being particularly susceptible to disease, it was really not safe
for them if he were to remain there. After some time, he agreed that he would
come back to the hospital. He said that the problem would be transport, because
he was not well enough to ride on our motorcycle back with us. This presented a
problem for us, because there is no real system in place for this sort of
occurrence. After a quick discussion, Jerome and I decided that we would go
back to the hospital, and I volunteered to cover whatever costs there would be
in finding a car to transport him. I felt that this was way too important to
ignore, and I couldn’t think of any cost that would be too great to protect
people from such a deadly disease.

Jerome got us back to KDH as fast
possible, and we got right down to business finding a car to get back to our
patient. Sean was thrilled that we had found him, and we were able to get one
of the cars from the established transport program, even though our patient
wasn’t enrolled in it. Jerome had taken a phone number of one of the patient’s
family members, so we called to let them know we were on the way back and where
to meet us. After the 1-hour drive up there, we found that they were not at the
meeting place. We went back to the house and found everyone gone – except for
our patient hiding under his blankets. We kept talking to him until he
consented to acknowledge us, but it was pretty clear what had happened. The
family had all gone away and conspired so that no one was there so we couldn’t
take him. We started to try to persuade him again, but he was very adamant
about not wanting to go. He kept saying that they weren’t taking care of him
and he was going to die there. Eventually, family members returned and we tried
to help them understand the seriousness of the patient’s condition and the
reasons why he needed to return to the hospital. We hadn’t wanted to pull out
this argument, but the reality is that TB cases are registered with the
government, and defaulting on treatment is taken very seriously. In the case of
MDR TB, our patient would be arrested and dragged to the hospital within a
couple of days at the most. When we told him this, he said, “Then let the
police come and take me.” Our explanations had persuaded the family though, and
with their help he eventually, grudgingly, consented to go with us. That was
fortunate, because I was going to camp out right there in that yard until he
agreed to go. There was no way after all the hours we had already put into this
and the level of risk that he posed to his family and community that I was
going to leave without him. He told us that he would only go on the condition
that if no one was taking care of him the next day, he was going to leave
again. With the help of his son and grandson we got him to the car, gave him a
mask to protect the rest of us, and all piled in for the trip back to the
hospital. We got him there, helped with his new interview, and made sure he was
settled before finally going home. I got dinner for him, his son, and his
grandson, and after 5.5 hours, called the quest complete.

Saturday was a much quieter day,
just nutrition follow-up surveys again. They went well, and in the afternoon
Hannah and I went for a nice hike up Crater Hill. That was a really cool hike,
because the top of the hill has a giant crater with a forest in the middle.
Really beautiful, and a nice quick hike. That evening we just worked on data,
made dinner, and watched the Lord of the Rings. Definitely can’t complain about
any of that. Sunday was also nice, since we had the day off we went to a nice
breakfast at the nearby hotel. Then I went to mass for my first church
experience it. To say that it was awesome is an understatement. It was really
nice because there is a mass in English every week, and the Catholic Church is
a two-minute walk from our house. It was really nice to be at mass again, and I
was totally blown away by the musicality of the service. The singing and
dancing was incredible, and was consistent throughout. It was similar to what
I’m used to at home, but different (and I think better) in many ways. Of course
the music was incredible, and I always find that to be one of the easiest ways
to connect spiritually with others and God. But I think what I most appreciated
was the sense of community, and the depth of people’s faith here. I do not mean
to say that the faith of people in the US or other places in the world is not
as legitimate or that it is insincere, but I think that to believe so firmly in
something when there is so much more hardship means something more. To see
families that have lost multiple children to disease or malnutrition or
horrible accidents still believe unwaveringly that God is good and watching
over them is extremely impressive. When people have so much less than most
people have in the US, and they don’t complain or sit jealously watching their
neighbors who have more, but rather thank God for all that has been provided
for them, it is striking. I have heard the parable that was in the reading this
week uncountable times before, but when I heard a story about farming while
sitting with people who actually toil in fields for a living and experienced
their understanding of it, it changed. The lesson this week was about patience.
It was about the kind of love and patience that God shows to us, and that we
should be showing to each other. I think that it was a good and necessary
message for me to be reminded of, particularly as I have been getting angry
with neglectful parents and hospital workers. We are all flawed, and none of us
should be so swiftly passing judgment on others. This is certainly more
difficult some times than others, but I felt as though there was a reason I was
hearing it when I did, and I decided to pray in that moment for the neglectful
parents and the x-ray technician instead of spending so much time being angry
towards them. I think that whatever your beliefs, if you have the opportunity
to go to church in Uganda some day, it is worth your time. Whether you have a
faith, and be it big or small, seeing the intense spirituality of these people
can’t help but move you.

After church we went for a hike to
the lake, but since the weather was bad we didn’t stay long. We just did more
work when we got home until later in the evening, when we made a cake to
celebrate Nate’s birthday. He had gone to hike one of the volcanoes, and since
we don’t have an oven, we made a cake by stacking crepes and putting different
fillings between each one. When the hikers got home we surprised Nate and sang
happy birthday and celebrated a bit. It was a nice night, and I was pretty
proud of the crepe-cake in the end, it was awesome.

Monday was a kind of disappointing
day because there had been miscommunication and the villages we were supposed
to screen for malnutrition weren’t ready for us. So we ended up going back home
and working with data instead. In the afternoon we went to the market and got
all the necessary ingredients to make an awesome chili. Then we went to a
spectacular dinner party! Dr. Michael, the medical director of the hospital,
and his wife, Jackie, had us over to their home for dinner. It was the most
spectacular meal I’ve had in ages. I ate enough for three large men, and it was
worth the strain it put on my waistband. It was really amazing, and so much fun
to spend the evening with all the students, residents, and a truly wonderful
family. There was a huge thunderstorm that knocked the power out, but that
didn’t bother anyone. It was a spectacular evening.

Tuesday I went out with Jerome
again, but no crises to solve, so a pretty standard day. Hannah and I made our
awesome chili in the evening and watched Aladdin while we peeled all the
potatoes and carrots and sorted the beans. Today we had focus groups in the
morning, and wrapped up our discussion of domestic violence. These two sessions
have been really eye-opening for me. Much of what the women shared was
disturbing to me, and there was a lot that I didn’t expect. Abuse is always
upsetting to discuss, but I didn’t anticipate the differences in experience
here and in the US. Many women here believe that a man who doesn’t beat his
wife doesn’t love her. Many also believe that if he has paid the bride price
that her parents asked, it is more ok to beat her than if he hasn’t. Half of
the time when they refered to their husbands, the women used the word “master”
instead of “husband.” They always refer to their homes as their husband’s home,
as if they don’t have any ownership in it. All of these things were horrifying
to me. In contrast to the US where abuse is most often secret and hidden, here
it is very much in the open and accepted. Although there are laws against it,
there is very little enforcement of them. I was very glad to see that the women
in our group seemed to grow through the discussion and recognize more of their
own worth and value. I really like how the lead facilitator, Joseph, pointed
out to them that their homes would completely fall apart without them. He asked
them about al the things their husbands depend on them for, and after they
listed all the things (a substantial list), he asked them who is really the
master? If the man can’t sustain his own home, can he really be the master of
it? If the women didn’t do all that they did, would the man live well? He made
them see their own power, and it was wonderful to watch. It was unfortunate
that the men did not attend these sessions, because I think that both groups
talking together would have made more progress. But I do believe that the women
left today knowing more and feeling more empowered than they had before.

I am already starting to get really
sad about leaving, I have learned so much and gotten to know so many incredible
people. Leaving will be very hard. I am so used to the way things are here, I’m
not sure how the adjustment back to NY is going to go. I have definitely picked
up some of the speech patterns here, so I know that I’m going to sound funny at
the very least. I’m sure I’ll also accidentally say words in Rufimbira a lot. I
think the most difficult thing will be the difference in pace and friendliness.
Not greeting everyone I meet on the street and everyone rushing around in their
own little bubbles is going to seem very strange after being here. The people
here are so unlike people at home, it’s almost impossible to explain. When we
go to a village looking for a patient, for example, we can just stop anyone we
see and ask them for help. People often drop whatever they’re doing and will
lead us to the patient’s house. They don’t act like it’s an inconvenience or
like we are bothering them or anything. People always have time to help each
other, and a visit from family or friend or stranger is always welcome and
treated the same. Nothing like being in NY where people always seem to be
annoyed if you speak to them. It isn’t like these people aren’t busy and don’t
have things to do, because they really really do. They work exceptionally hard
in most cases. But they have a very different value system, and I have found it
really inspiring and humbling to see the way that people treat each other here.
One of my favorite things that people say here is whenever you arrive at a
place, whether the people know you there or not, they always greet you with
“you are welcome.” And though it is the customary thing to say, it is also very
clear that people mean it. As a foreigner, I have appreciated that immensely,
but I think that as human beings in general, being truly welcomed wherever we
are is one of the best feelings we can have. I am going to miss that sense of
acceptance and belonging very much. And of course the scenery, that’s going to
be rough. I’m going to have a hard time looking at concrete again after so much
time surrounded by lakes and mountains and going hiking anytime I feel like it.

July 11, 2014

Liz in Kisoro, Uganda

We are rounding out week 5 in Kisoro District and it’s almost time for me to head home… unbelievable! This summer was exactly what I needed between MSI and MSII to remind me why I entered medicine. The hospital staff and the partners we work with here are very dedicated, passionate, and genuine. It’s really been a pleasure to be a part of such a committed team.

Most of our work here is monitoring and evaluation of current nutrition, chronic disease, family planning, and village health worker programs. As fresh MSIIs, we have little to contribute in a clinical setting. However, while in the villages talking to parents, we are often asked clinical questions. Our foreign appearance and accent somehow seem indicative of medical credential…

We tend to be overly apologetic about our lack of knowledge and qualification, are cautious of giving false hope, and are fearful of doing harm through overstepping rank or through guarded silence. Yet villagers still want our advice, our opinion, anything we can offer that might help. Though not often externally emotive, they want the best for their families and are open to new ideas.

This week we began the nutrition follow-up project. Through the Village Health Worker network, the Nutrition Program screens children by measuring their MUAC (mid-upper arm circumference) and weight. Those children who are underweight for their age or have a MUAC less than 12.5 cm are entered into the program. These kids receive nutrition supplements like Plumpy Nut ® or Unimix, depending on what is available.

We reviewed the database of previously malnourished children who graduated from the nutrition program. Then, we sorted the kids by village and made a plan to find the children who were designated “cured” (as opposed to drop-outs or children who died). The goal of this adventure was to see if their health had been maintained since graduating from the program and learn about ways to improve our approach.

At 8:00 am Hannah, Cynthia, and I split up the villages with our counterpart translators- Julius, Dickson, and Vallence- and made our way up the rocky path that the driver managed to tame into a road. Vallence and I had a list of 20 kids to meet in two days. The VHW met us at the village center and led us to the first home.

Waraye… (Good morning.)Yego… (Yes.)Mezute? (How are you?)Daho… (I am fine.)Mr. R was young, slight, and spoke in a controlled, cautious, and calming manner. He’d just woken up and exited the house while putting on his shirt. He, Vallence, and the VHW sat on small hand-carved stools less than a foot high. They looked like something you would see in a museum exhibit of African art and artifacts. I sat on the steps to the front door. We introduced ourselves, why we had come, and spent some time trying to understand the relationship of this man to the children we were tracking.

It turns out that Mr. R’s brother had gone to the city to find work. He lived there for most of the year for many years. Most likely, this is where he had contracted HIV, which later infected his wife and at least one of their four children. Two of the children and their mother were enrolled in the Nutrition Program. The supplements had helped for a while, but when the husband died of pneumonia the family lost much of their financial security. The wife died soon after, having become hopeless, depressed, and alcoholic. After she died, the youngest child lacked a primary caretaker and soon passed also.

This was going to be an intense day. I wondered how Mr. R felt about answering my questions. “Good morning, please tell me about your dead brother, sister-in-law, and niece.”

Mr. R was now left to care for the four remaining children in addition to his own. Vallence and I asked him about his own health and support system.

“I have not shared this story with anyone. I must study the villagers. It may be that my worries are not as grave as theirs. I do not want to contribute to another’s burden when it may already be worse than my own.”

We recommended that he meet with the hospital social worker to seek out additional support services.

“I want to test the children for HIV, but I don’t know how to tell them…”

Vallence dove in to answer this one and was a total pro. He works with many NGOs and knew exactly where to find help. They made plans for another meeting.

I offered what I could, “You know the stigmas around HIV. Once the children know what happened to their parents, it will be very important for you to remind them that you love them, that you will take care of them, and that their parents were good people who loved them very much.”

It seemed obvious, but needed to be said. So many children orphaned by HIV are seen as burdens, resented for their circumstance.

We found the surviving child from our Nutrition Program at school. She was very thin, shy, and several grade levels behind. It is common for malnourished children to fall behind- it is hard for them to focus and often the underlying problems affect their attendance. This girl had to help care for siblings at home, so she often missed school. We measured her in the headmaster’s office to provide some privacy and moved on.

While walking to the next home, Vallence delivered a passionate monologue on the cycle of malnutrition. “These kids are malnourished, fall behind in school, get discouraged and drop out. Then they marry young, have many children, and produce more malnourished families.” The solution seems to be immediate financial support for food, family planning counseling, and tutoring to help the kids keep up with their grade level. All of this costs money and the Ugandan health and social services sectors are already grossly understaffed.

We traveled to a few more homes, walking carefully between the volcanic rocks, through the dust of dry season, and avoiding the fresh animal droppings in the road.

The next parent we met with was Mr. Q. He was strolling to town with a group of friends who joined him for the consultation (privacy is relative here…).

Waraye…Yego…Mezute?Daho…

We talked about his children, asked why he thought they were malnourished, and what advice he had for improving the program. He explained that around the same time that his first child started having chronic diarrhea and entered the Nutrition Program, his wife stopped breastfeeding because she was pregnant again. He believed that pregnancy made the breast milk dangerous for his first child.

This reminded me of an experience in Togo- people believed that eating too many mangoes could cause malaria. In reality, the unwashed mangoes (or unwashed hands ripping into the mangoes) carried intestinal parasites and bacteria that led to some of the same symptoms as malaria. The mangoes came when the rain came, which is also when the mosquitoes brought malaria. People assumed they were connected.

I suggested to Mr. Q that perhaps the breast milk wasn’t causing the illness, but that it might be that the child’s newfound mobility was introducing her to parasites in the soil, carried by animals in the compound, or through the new foods she was trying. We talked about home sanitation and family planning. His friends had many questions about the side effects of birth control methods. Mr. Q told me all about what he had learned in the nutrition program: the importance of eating greens, diversifying the diet, and heating food. We wrapped up and moved on to the last home.

Ms. M had six children under seven years old, including a set of twins. Two had been in the Nutrition Program and we screened the others who were under five years old. The kids were sweet and agreeable. It was nice to complete a visit sans mzungu tantrum (children screaming in fear of foreigners).

At the end of the visit, I noticed a depressed fontanelle in the youngest of the children and asked to hold him. The baby was chubby and his skin didn’t tent when pinched. His eyes were not sunken, but I have never seen pupils so small.

“He is sick,” Said Ms. M.

“Yes, I see that… Has he been vomiting or had diarrhea?”

There was a pause.

“He had Gapfura for a week, with a cough… we took him to the local surgeon.”

I’d heard about this from the MSIVs, but hadn’t actually encountered it yet. Gapfura is a kind of folk illness that is cured by a crude tonsillectomy. A traditional surgeon cuts the back of the baby’s throat and often this procedure results in infection. The parents bought Ampicillin and Paracetamol at a local shop, though they hadn’t been instructed with regard to dose. I couldn’t find a pulse.

Vallence explained the dangers of improper dosing to the parents. They were afraid for the baby, but also fearful of seeking medical attention. Vallence told me about how many parents travel long distances to the hospital only to find that the doctor is unavailable or censures them so harshly that they fear seeking attention in the future. They knew that taking the baby to the hospital could have similar outcomes- a day of work wasted, five other children left home alone, the expense of transportation, along with being shamed by an authority. Life was already stressful and money was tight. Yet, the traditional healer is always available, more kind, and not as expensive as transport to town.

“Let’s take the baby and Ms. M with us to the health center. He needs fluids and surveillance.”

This was a tough sell, but after 30 minutes of negotiating, mom and baby came with us. We promised that one of us would go with her to make sure the nurse treated her well.

When we arrived, the nurse at the health center was in a meeting. We stated the emergency and he placed an IV.

“She is very nervous to admit that the baby had a crude tonsillectomy, so let’s be gentle with her.”

This was not necessary. He knew.

“Have you seen this often before?”

“This is very common. It is rare that the parents want to tell you they went to a traditional surgeon. It’s good she came in so soon. Usually, they are much worse by the time they get here.”

It was 3:00 pm. We left Ms. M with the nurse and drove home. Only after sitting back in the van did I realize how tired I was, my feet caked in dust, that I hadn’t eaten all day… It didn’t matter. Though only an MSII, I was a part of a medical team. I had known enough to do some good. That’s why I wanted to join medicine in the first place. It’s easy to get bogged down in the mental strain of medical school in the first two years and I’m so grateful to have had this re-centering experience.

Follow-up: Vallence is organizing an HIV screening day for the whole village where Mr. R lives and arranging for several special consultations with social workers and nutritionists. Ms. M’s baby was released from the health center the next day and is recovering well.

July 16, 2014

This is Hannah again from Kisoro, Uganda. We’ve been
here for about 5 weeks now. In my last blog post I talked about many of the
good things about the VHW program in Kisoro, and this time I’m going to talk
about some of the things I’ve struggled with while being here. Lately we’ve
been focusing on two nutrition projects, one where we go out to villages and
screen children for malnutrition, and a second project where we follow up with
children who were previously malnourished to see how they’re doing now. This work
has been very interesting because it’s given me a much different perspective of
malnutrition and its causes. I
used to think that malnutrition in developing countries was just from children
not having enough to eat, but now I realize it’s much more complicated than
that. For example, many children are picky and will only eat Irish potatoes,
the staple food here, which leads to malnutrition because of lack of nutrients.
Also, many mothers stop breastfeeding children earlier than they should for
various reasons, one being that they become pregnant again and think it’s
unhealthy for either the fetus or the young child. Despite these reasons, there
is definitely still an association between malnutrition and poverty, because a
lot of mothers will say they know they should be feeding their children beans
and vegetables instead of potatoes but can’t afford to buy them.

One of the saddest things for me
personally here has been seeing children who are not enrolled in school. In Uganda, parents have to pay school
fees every year for their children to be in school and buy school uniforms,
which some parents cannot afford. A six year old who is not in school now will
probably have a difficult time catching up to her peers if she ever does
eventually enroll, and is more likely to marry younger. I’ve tried to counsel a few families
about the importance of enrolling their children in school but I’m not sure if
we were really on the same page. I do think that getting every child into school,
and keeping them in school, is one way to break the cycle of poverty for some
families, the question is how to achieve this.

One thing that’s been difficult for
me is that a lot of villagers don’t really understand that I’m a medical
student, not a doctor, so they come up to me with all their medical problems,
expecting me to help them. I’ve
had parents bring their sick children for me to examine, but best I can do is
advise them to go to the hospital.
In one village the other day, an elderly man kept asking me to see a
psychiatric patient in his village, and I said over and over that I have no
training in psychiatry and wouldn’t know what to say, but I felt bad that I
wasn’t able to help. I’m going to try to connect him with one of the hospital
psychiatrists so hopefully he will get the help he needs.

The thing we’ve been doing that I think has helped these sick
villagers the most is transporting them to the hospital in our work van on our
way home, since we’re going in that direction anyway and the hospital is a very
far walk for many of the villagers. We’ve brought quite a few patients to the
hospital by now, mostly children along with their mothers. Two days ago we brought a very
malnourished child who was being looked after only by his 11-year-old sister at
home. A few days before that we
brought a child who had just undergone a crude tonsillectomy, which is when
parents hire a local villager who is not medically trained to scrape out the
child’s tonsils and cure them of “gapfura” which is more of a folk illness
here. This usually does more harm then good and many children acquire
infections from this procedure and sometimes become septic if not taken to the
hospital early enough. It was difficult to convince this family to bring their
child to the hospital because hospital workers have a reputation for yelling at
parents for doing crude tonsillectomies on their children, so parents don’t
bring their children to the hospital after the procedure for fear of being
insulted. This is dangerous for the children because the longer the parents
wait to seek medical care, the higher the risk of death for the child. Luckily,
we found this child only one day after the procedure and were able to bring her
in while she was still relatively stable, so it seemed like she will be fine. I think that in order to eliminate this
dangerous procedure, there needs to be a combination of greater education for
parents and also better treatment of healthcare workers towards families that
underwent the procedure.

Another thing that has been
different for me here is the amount of freedom that medical students in Uganda
are given to see patients and do surgeries and procedures on their own, versus
in the US where medical students are much more restricted about what they can
do and what must be supervised. I
shadowed a medical student on the pediatrics ward and we were seeing patients,
he needed a break and asked me if I could finish up seeing the last few of his
patients for him. I felt uncomfortable telling him no but had to explain that I
did not have the training at this point to do that. I also spent a day
shadowing with Marie Stokes, an NGO that does family planning work. I was
observing a doctor inserting implants, which is a hormonal device that goes
into a patient’s arm. He injected lidocane, inserted the implant in the first
patient, and then turned to me and said “your turn for the next one!” Again, I
had to explain that this was not something we would be allowed to do in the US
and I didn’t feel comfortable doing it. It’s been hard to find a balance between
wanting to learn new things and also knowing what my limits are and when to say
no.

Week Five

Cynthia from Kisoro, Uganda

July 16th, 2014. Week 5 has been an interesting mixture of nothing happening
at all and then a lot happening at once. First, we have a nice group of new
friends here in the form of two residents, a fellow, and a nurse from the US.
The residents, Nate and Sean, are from the family and social medicine program
at Einstein/Montefiore, and they are here for one month. They are both really
awesome people with great stories, and they are a lot of fun to hang out with
and learn from. Having them here helps a lot, since for the last month the
hospital really hasn’t had any doctors at all. The fellow, Nori, is literally
the most awesome and impressive person who has ever lived. I couldn’t invent a
more incredible life story for someone if I tried. He works at Montefiore also,
very closely with the global health faculty, and he has been coming here a few
times a year for the last couple of years so he is very familiar with
everything. He is exceptionally helpful at making the hospital run more
smoothly, and he is a wonderful teacher, so it is spectacular to have him here.
Adam, the nurse, has just arrived, but he has also been here in Kisoro before
and seems really great too. So we are all pretty happy with the crew that we
have, and it has definitely made all of our group dinners more exciting.

Unfortunately, while we are saying
hello to all of these great people we are saying goodbye to Liz. As great as
all these new guys are, there is no one and nothing that can replace Liz. The
three of us girls have spent so much time together these last five weeks, and
Liz has taught us so much, I just don’t know how we will finish this trip
without her. I’m really happy that we got to have a celebration for her on
Sunday though. Since Sundays are our only days off, we dedicated the whole day
to Liz. In the morning we hiked over to the nearby lake, Lake Mutanda, and we
relaxed and swam for a few hours. Then we came back to our house and cooked a
giant dinner. We had all of our Ugandan friends over as well as all of our
American friends, and we had a nice big celebration. It was pretty great, and
Liz was extremely happy. It is so sad to see her go, but I think we have
learned enough to make her proud the rest of the way here.

Up until Sunday, we had a pretty
normal work week. Tuesday, Friday, and Saturday we had nutrition follow-up
surveys. They have been going well generally speaking, we have seen a good
proportion of the kids we want to find in each village and we are collecting
data that we think will be really helpful at evaluating and improving the
nutrition program. Wednesday we had our focus groups, and we did a session
about sanitation and diarrhea. It may not sound like it, but it was a lot of
fun. We had drawn out some comic strip-type stories to illustrate different
methods of the spread of germs that cause diarrhea (the four F’s: fingers,
flies, fields, fluids), and we did a demonstration of how to make oral
rehydration salts (ORS). The villagers were laughing and having fun and
definitely learned a lot, so I felt like it was a good session. After that we
just did a lot of data entry and analysis work, it is really never-ending.

Thursday was a lot of fun because
we got to shadow in the chronic care clinic with the residents and Nori. I feel
like I learned more that day than I have in weeks at school. I saw some really
interesting cases, learned how to tell the difference between malaria and
typhoid fever, heard some very bizarre heart murmurs, and generally was
reminded of how great medicine is. I am so happy every day that this is the
path I have chosen. One of the best things about days at the hospital is that
everyone goes out to lunch together at a restaurant right across the street
that we just call “beans place.” As the name implies, we eat beans there, and
they are bloody marvelous. It’s a huge amount of food for less than a dollar,
and it is just great. After lunch, the residents and Nori went back to work on
the wards and we had a meeting with some of the administrators here to present
our findings from surveys we did earlier in our stay. We had interviewed all of
the new VHWs to get an idea of what their experience has been so far and any
issues they are having. They had a lot of good suggestions and some recurrent
issues, so we presented all of those findings to Deus (the head of the VHW
program), Sam (one of the other program leaders), and Dr. Michael (the medical
director of the hospital). It was a really great meeting, and I think that we
were able to share a lot of helpful things with them and that we came up with a
good plan to keep the program moving forward. After that, as always, Thursday
is market day. We had a particularly good market day at the big market where we
were able to find a lot of great fabrics and get some gifts for people.

Friday was the big day that kind of
still has me unsettled. I have not included names of people or places involved
to protect their privacy. We went to do more nutrition follow-up surveys, and
since this one village had a huge number of kids, we all went together. The
surveys went well and everything was good until the end of the day when we were
finishing up and getting ready to leave. There was one little boy who we found
was malnourished, but there were no parents or anyone around. The villagers
told us that the boy is 9 years old, and that his 11 year-old sister is his
primary caretaker. This was disturbing information for several reasons. First,
the fact that he is 9 seemed nearly impossible because he is the size of a
small 3 year-old. Second, an 11 year-old girl taking care of 4 other siblings
is generally appalling, and very worrisome for the future health and wellbeing
of all of them. There is no way that she can go to school, it is unlikely the
others will go to school, there is no way for them to get money to buy food, it
is extremely improbable that they can raise enough crops to feed themselves, and
the whole situation can easily spiral into early marriage, disease, death or
one of several other depressing outcomes. We learned that the parents had
divorced and the mom left the village while the children stayed with the
father. They told us that the father was sick and incapable of, or unwilling to,
care for the children. Looking at this 9 year-old boy, we knew we had to take
him to the hospital because his malnutrition was severe. So we began a quest to
find an adult who would be able to accompany him to the hospital. The villagers
thought that maybe a grandmother would be able to go with us, and they sent
someone to find her.

While we were waiting for someone
to come, we tried to find out what we could about the family and the boy. All
of it made me really angry. I could not and cannot understand what would ever
make parents completely abandon and neglect their children. Seeing these 5 kids
all sitting there dirty and hungry and afraid, the poor oldest girl doing her
best to look and act like an adult while having no idea what to do, was one of
the most heartbreaking experiences I have ever had. This is not, of course,
unique to Uganda. There are children neglected in much the same way in the US.
But I have never seen it, and this first experience with such a situation will
not leave me anytime soon.

Eventually, much to our surprise
considering what the villagers had told us, the father of the children arrived
and agreed to accompany us to the hospital with his son. When we went to walk
to the car, the boy did not seem to want anything to do with his father, and
when Liz went over to him, he was more than willing to let her carry him. That
may be the greatest understatement in the history of time. He clung to her
desperately, in a severely needing way that seemed to indicate that he may die if
she ever let go. When we got to the car again, one of our friends/translators,
Julius, got the boy a snack and a drink from a shop along the road. Then we
began the long car ride back to the hospital. We tried to have the boy sit with
his dad, but he was not happy there, so he sat with Liz for a while. Eventually
she decided that since she would be leaving soon, it would be better for the
boy to bond with someone who will be around longer and can see him in the
hospital, so he came to sit with me. I cannot describe the way it felt when he held
on to me. I have held very many children before, and never have I experienced
anything like this. He wasn’t holding on like “oh this is a nice place to be, I
can stay here” like most kids do. He was latched on with an iron grip, and if
my arms around him were even slightly slacker than his own arms around me, he
would whimper and squeeze that much tighter. The intensity of being needed this
way gave me feelings I don’t know how to put into words. There were a lot of feelings,
and they included that same anger that I felt toward his parents earlier,
because what kid is more comfortable with complete strangers than his own
father? What is going on in his life that he responds this way? How long has it
been since he has felt a caring touch? The dominant feeling that surfaced
through all the others, however, was a fierce determination to do whatever may
be necessary for this child. I was ready and willing to fight to the death for
this boy. I have never had anyone need me the way he thought he needed me, and
I refused to betray that kind of trust.

When we got close, we stopped by
our house and Liz collected a kind of care package for them for their stay at
the hospital. Then we finally arrived at the hospital, and we brought him to
the pediatrics ward to get him admitted and start evaluating his condition.
This proved to be more difficult than anticipated because we couldn’t find
anyone on the pediatrics ward at first. Eventually a nurse arrived, but she
refused to believe that the boy was actually 9 and that he needed to be there.
Thankfully, we found some of the 4th year students and Elena came to
help us and get his admission note ready. Nori was concerned about possible HIV
and had us do a rapid test, which was thankfully negative. Liz went to go get
dinner for the boy and his father while I stayed with them. After going through
a full interview and part of a physical exam so that they were ready to be
admitted and get settled, the father told us that he is HIV positive and didn’t
bring his anti-retroviral medications, so they would have to go home. I begged
and pleaded and argued as hard as I could in every way that I could think of to
keep the boy with us at the hospital. It had taken so much to get him there, he
was clearly scared and confused, definitely not a normal size or at a normal
developmental stage for a 9 year-old, chronically malnourished and mistreated,
and they wanted him to leave and come back on Monday. I lost this battle. I was
terrified that the father would not bring the boy back on Monday. I did not
trust him at all, the way the boy did not seem to even like him disturbed me
intensely, his contentment to allow his 11 year-old daughter to run his
household infuriated me, and I felt it nearly equal to endorsing abuse to let
this boy leave with him. But we took every possible precaution, informed the
village VHW, and sent our own transport service to pick them up on Monday to
bring them back. This was successful, and the boy is now at the hospital being
evaluated and treated. On Friday evening when I watched them leave, though, I
was utterly distraught. This whole encounter has really made me extremely
grateful that I am going into medicine, but it has also made me think a lot
about where I want to work later in life and who I want to be helping. I don’t
know the answer to that question yet, but this boy has given me a lot to think
about.

Saturday was another nutrition
follow-up day, as were Monday and Tuesday. They were not really remarkable in
any way, except that on Tuesday not one of the children we weighed or measured
cried at all! That was a first, and a very welcome one. Last night was Liz’s
last night here, so we went on one final hike together and Wanda made a
spectacular cheesecake to celebrate. Early this morning we woke up to say
goodbye to Liz, which was very hard. But the day has gone well since then, and
we had a good session with our focus groups, beginning a discussion about
domestic violence. Later tonight when we have dinner without her I think we
will really feel Liz’s missing presence. At least the last few weeks we will be
really really busy so that it will be hard to notice how much we miss her. I’m
definitely missing everyone at home too, but I am appreciating my experience
here more and more every day. I never expected that this trip would change me
so much, but I know that I am not going to go home the same person I was when I
started this journey. I don’t think that’s a bad thing, and I am kind of
excited to see where the new me finds herself going after this.

July 11, 2014

Week One in Uganda

We have been here for one week now! It’s kind of crazy. It feels like we’ve been here much longer since we’ve settled in so much. I thought
adjusting would be more difficult, but it actually hasn’t been bad at
all. I’ve gotten used to the no refrigerator or microwave, no kitchen
sink, no hot water, boiling everything, brushing teeth with bottled
water, tucking in my mosquito net all around my mattress at night etc
etc so it all feels pretty normal and natural already. I’m probably
going to get back to the states and do weird things. But life is
really good here. The weather has been very mixed, and not what I
expected at all. Since we are up in the mountains, it isn’t very hot.
Some days it can be quite chilly. The rainy season is supposed to be
over, but it seems to be clinging on a bit, so we have had more cloudy
days than sunny days, and it is supposed to rain most of this next
week. I’m hoping we get some more sun soon though, because when the
sun is out and the clouds burn off it is hot and lovely and all the
mountains that have been hiding behind the clouds and mist are
visible. Attached is a picture from one of the sunny days of our
biggest volcano! I really hope that it does start being warmer more
consistently since we had a rough winter at home and I just want to be
warm finally.

The week was really good, I got to do all different activities and see
many different aspects of the system and get a lot of varied
perspectives. On Wednesday we led focus group discussions in a couple
of villages, and that was so much fun and very interesting. We were
supposed to lead the groups in pairs, but one of our group has been sick
most of the week so I led our group by myself. It
wasn’t really by myself though because we each also had a counselor
from the hospital and a translator with us. Joseph and Julius were the
two who worked with me. The village where my groups are is called
Nyagihenge. It is exceptionally beautiful, pretty much right in front
of the volcano. I was super surprised at how many people showed up for
the group, especially because this program was new to this village. We
had expected maybe 8 each for men and women, but we had 25 in the
men’s group and 18 in the women’s group. We spent 1.5 hrs each with a
group of men and a group of women. The topic was stress and how to
manage it, and it was so interesting to hear everyone’s thoughts. When
I asked them at the beginning to define what stress is, they gave some
really eloquent and poignant descriptions since the word itself was
very foreign to them. My favorite response was from one man who said
“you have one worry and then another worry and then another worry, and
they are all in your head at the same time. This means they keep
crashing into each other over and over so that it is hard to make any
of them get better.” I found it very interesting that the men and
women listed almost identical stressors in almost exactly the same
order. I thought is was profound that the worries these people had in
a tiny village in rural Africa were the same worries most people have
back home. Their biggest concerns were about their children – children
being healthy, children behaving well, children doing well in school,
being able to pay for school. I really loved how much our discussion
emphasized how undeniably alike all people are in the end. The biggest surprise for me came when we asked the groups at the end of the
discussion what topics they would like to talk about in future
sessions (we will be there every Wednesday). It blew me away that the
men said they wanted to learn more about family planning, pre-natal
care, and domestic violence. Even though these sessions are some of
the most work that we have to do here because we have to spend a lot
of time making plans for them well in advance, I know that they are
going to consistently be high points of my week.

Thursday was a pretty quiet work day because we stayed at the compound
and worked on organizing data from the nutrition program here. We are
going to be going out to the villages where the nutrition program for
malnourished kids has been going on for a long time and try to follow
up with the kids who finished the program to see how they are doing
now and how they/their parents think that the program impacted them.
In order to do that we had to sort through all of the data that has
been collected over the years and find all the kids who have been
cured along with their identifying information so that we can locate
them in the villages when we go to do the surveys. I’m really excited
about this project and the other work we are going to do with the
nutrition program because it can have a huge impact and save/improve
the lives of so many children. The nutrition program itself consists
of identifying children who are malnourished, delivering regular
nutrition supplements to them, educating their caregivers about
nutrition, and monitoring the children’s progress. If they do not
improve with the supplements at home, they are sent to the hospital
where they can be treated on an in-patient basis until they are more
stable. We are hoping that our follow up surveys will show that the
program has made a positive difference to the children and the
families. Later this month we are gong to expand the program to new
villages, starting with big screening days weighing and measuring all
of the children in each village.

The best part of Thursday was going to the market in the afternoon.
Monday and Thursday are our market days, and I know that is what I
will miss most about life here when I have to go back home. Getting
pounds of fresh fruits and vegetables for a few dollars total is
amazing. It is way more fun and way better tasting than supermarket
shopping, especially supermarket shopping in the Bronx. We got so much
food this time because on Monday we were way too timid and ran out of
everything super fast. There is so little we need to go to the
supermarket for here, basically just peanut butter, dairy, and canned
things. In addition to raiding the vegetable market at the end of our
driveway, we went down to the big market in town, which is like an
explosion of people and colors. Anything you could ever need you could
find at the big market. Liz is experienced in all these things, so she
showed us how to pick out nice fabrics that we then took to the local
tailor who is now making us our own traditional Ugandan clothes! I
will be sure to send a picture of that once we pick them up. To buy
the highest quality fabric and have my own custom dress made, it cost
me a total of $12. It is going to be impossible to return to New York.
We had a great big potluck dinner with all the students here that
night, and the girls who have been here for the year really know how
to cook with the food and materials here. I took the easy way out and
made guacamole, which is awesome because the hardest part was making
sure the raw vegetables were clean and no one will ever complain about
there being lots of guac. I am definitely going to apprentice myself
to Wanda though, she knows where to get the best of everything in town
and has some of the most delicious recipes.

Friday was a more interesting day because I went out with a project
assistant named Jerome for the chronic disease follow up program. What
we do there is go out to the villages and find people who missed
appointments in the clinic. We see how they are doing and try to find
out why they missed the appointment and try to convince them that they
should be in treatment. I really liked it because we got to go to so
many different places, and the process of finding patients means we
got to talk to lots of different people. It was really remarkable
seeing where people live and being invited into their homes. Almost
everywhere we went we had to park when we got kind of close and then
hike over to the patient’s house. There was definitely a range of
homes, some larger or smaller or multiple buildings, but most were
made with mud walls with wooden skeletons and metal roofs. We didn’t
have a great success rate, unfortunately, only finding 2 out of 7
patients on our list. It was a very sad day because 2 of those we
didn’t find we learned had passed away. This was my first experience
sharing in someone’s loss here, and I found the language barrier more
frustrating than ever. I think that in these times words are not
really the most important though, and I felt that just being there
sharing in grief together was meaningful. I am looking forward to my
next day out with Jerome, and I am hopeful that we will find more of
our patients in better health.

I’m still not used to being a sort of celebrity presence. Having
people stare at us and chase us and yell after us all the time is
totally crazy. When I was out with Jerome even just driving by, people
along the streets were yelling “Mzungu! Mzungu!” (the word for “white
person”) and sometimes “How are you?” which is the only English phrase
many people know. When I went running in the afternoon, I ran by one
of the schools when the kids were getting out (which is late here,
around 5:30) and about 20 of them swarmed around and ran with me for
about 10 minutes. It made it a little harder to run because all the
kids wanted high fives or to touch my arms or hold my hand, and one
figured out I was ticklish, but it was definitely a lot more fun than
running by myself (which is a real pain here still because of the
altitude).

I was lucky to have the day off on Saturday, but without everyone else
around it was pretty quiet. I would have gone adventuring, but it was
rainy and cold, so I stuck around the compound and got things done
here in the morning. Thankfully it cleared up a bit in the afternoon,
so once people got home from work Liz, Hannah, and I went on our first
hike up Hospital Hill, led by Emma. It wasn’t a terribly long hike,
but the ascent was very steep and there wasn’t exactly a real trail.
The view was amazing though. On the way up we got a spectacular view
of our town and the hills and mountains all around us. If it had been
a clear day we could have seen for miles and miles. At the top we
could see the other side of the hills to the beautiful lake. I
attached a couple of photos from the hike also even though the clouds
and mist make it hard to see everything. It is so beautiful here, I’m
not sure it is a real place sometimes.

Today we are going to hike to the beautiful lake we saw from the hill
with the older students and some of our Ugandan friends from work. I
am sure it will be another lovely day. I am looking forward to all
that this next week will bring, and I will try my best to keep you
updated. I hope things at home are good and that someone is watching
the World Cup for me, since we don’t have tv here and we’re missing
it. So much love to everyone, look after the USA for me.

Week Two in Uganda

It is hard to believe we have been in Kisoro for two weeks now! In some ways it feels like so much longer because we are so comfortable and settled in, and in other ways it feels like a blink. We are getting to be very busy, so the time is really flying. This week has been extremely packed and exciting, it feels good to be getting into a routine and starting to understand everything better.

On Monday and Thursday I went out to do interviews with some of the new Village Health Workers (VHWs) that are currently in training. It was a lot of fun to get to talk to them and hear about their experiences. Most of the VHWs are women, and a lot of them bring their children with them to things, so that is lots of fun because I got to play with babies while we did the interviews. In asking the VHWs about their work, I was really pleased to see that they are all so enthusiastic about everything. I didn’t realize until I talked to them how much work they actually have to do, and it was extremely impressive how they are able to balance everything. As I mentioned, most of the VHWs are women, and most of those women are pregnant or have several small children in addition to their duty to work their land and then be responsible for the health of up to 700 other households. None of those are small tasks, especially because the average household in the villages has at least 8 members. I was truly inspired by their dedication to the program, despite any challenges they have faced and sacrifices they have had to make. All of them describe their position as one of honor and privilege. Several described it as a calling, and something they hope to spend the rest of their lives doing. This hit home for me in a big way because it resonates with how I feel about going into medicine. So many of the VHWs talked about how important it is to them to serve their community and educate people who don’t know about important health issues, and they all truly believed in their ability to make big impacts and save lives. I understood their feelings so easily, and looking at many of these women who are so close to my own age, I wondered if they had been born into circumstances like mine, maybe instead of 5 children they would have 5 years of post-secondary school education like I have now. Such thoughts don’t seem to ever cross their minds, and they are some of the happiest people I have met here, which means easily some of the happiest people I have met in the world. But I thought about it because their spirits and convictions about their purpose were so strong, and I feel like medicine could definitely use more people with that attitude. After speaking to them, I feel ashamed for ever thinking I have had a lot of work to do. They are beyond incredible, and although I am here to teach them, I think they are teaching me a lot more so far.

Monday was otherwise only significant in that it was the first clear night since we have been here and I finally got to see the stars. If you are not aware (doubtful if you’ve spent any measurable amount of time with me), I am mildly obsessed with stars. The greatest present I have ever received was having a star named after me. In the Bronx, the unfortunate reality is that the stars are simply not visible. The most stars I saw at one time this entire year was 5. So since the minute I got here I have been watching the sky exceptionally intently. Because of the cloudy weather we have had most days, this was completely unsuccessful for a full week. But Monday it was finally clear, and it was worth the wait. It was like sitting under a great, glittering dome. There really aren’t words for it, but it was marvelous. I sat out there for a good amount of time, just enjoying the sky and the quiet, drinking hot chocolate and thinking that heaven might be something like this.

On Tuesday I went out to two villages for what we call “supervision.” Twice a month, a supervisor visits each VHW and checks on how they are doing and verifies that they are correctly identifying and treating cases. For some of the VHWs who have been working for 6 years now, that can involve some pretty impressive stuff. I went to two villages with two of the new VHWs I had interviewed who are still in training. That meant they didn’t have too much going on yet, but it was fun to go around with the supervisor, Evary, and learn along with the new VHWs. We got to visit a few mothers who gave birth within the last two weeks, and that was wonderful. I think that in many ways it was similar to what would happen in the US when the baby visits the pediatrician, but I think that the emphasis on nutrition and family planning were probably a bit heavier than we see at home. While we were walking around, Evary asked me about malnutrition in the US. He was completely shocked to learn that malnutrition the way they have it here is a very rare occurrence, because here it is at near epidemic levels. Evary works on the pediatrics ward, mostly with malnourished children, and when I tried to explain to him that we have a problem with obesity in children under 3, he really struggled to understand how a really fat baby could be a bad thing. I tried to explain to him that it’s not so terribly different than the malnutrition in children here—that in most cases it isn’t because they don’t have food to eat, but that they don’t have the right food. I tried to explain that families in the US have too many options, and they often choose the wrong ones, so that children still don’t get the good and important things that they need. It was a very interesting conversation, and I think that we both learned a lot about the issues we’re facing.

In the village that day shortly after our malnutrition discussion, we visited a home with many children where I was given food from a family for the first time. I was extremely touched because I know that they don’t have food to spare, it was a very bad year for all of the crops, and the yields have been very poor. I would have refused it, but that would have been taken as extremely rude. Everyone here is always so kind, and they all go out of their way to show me the greatest hospitality already, when they brought out a huge bowl of food I was nearly brought to tears. It was very simple, the food that everyone in the villages eats – beans and yams (the white and purple ones, not the American kind). But it was very tasty, very plentiful, and very timely because I was getting quite hungry. I don’t think that I have ever felt so welcome and so appreciated as I did in that moment. And I really hadn’t done anything to deserve it. I’ll never forget how happy they were that I ate everything, and they couldn’t stop thanking me for thanking them. It was extremely humbling, and likely to stick with me for a very long time.

Wednesday was time for focus groups again! This week was even more fun than last week. This session was about family planning, a very important topic here where most people know very little and having children too close together is a big factor in the malnutrition problem. We had a lot of fun talking about the advantages and disadvantages of family planning, answering questions, and clearing up misconceptions. Some of the commonly held beliefs were really interesting and crazy, such as a condom can go inside a man’s body and travel around causing problems. By the end of the session, I think everyone learned a lot and they were really excited to tell other people in their village about what they had discovered. We had a lot of people there again, just a few less men the week before because a bad thunderstorm a few days before had damaged many fields and they were trying to salvage whatever part of the harvest they could. When I was sitting safely at home watching that storm, I was just enjoying the lighting show like I usually do. Hearing the stories from the villagers about how it had flooded their roads, destroyed part of the small harvest they had this year, and that there were even several deaths caused by lightning strikes, really changed my whole perspective on it. I don’t think I’ll ever watch thunderstorms the same way again.

In the afternoon we hiked up Hospital Hill again, which we are trying to make part of a regular exercise routine. The ascent is super steep, so it definitely gets the job done. We also got to pick up the clothes the tailor made for us, which was super exciting. I love the dress I got! It’s so cool having something that was made just for me. There will definitely be more trips to the tailor soon. Pictures to come soon too, I promise I’ll work on that. Our afternoons this week have been pretty busy with meetings and planning because we are getting more into the projects we are working on now and there is just so much data that needs to be analyzed. Most of the week, our free time was spent on that.

Friday was a different kind of day because we shadowed the VHW training day. It was a lot of fun to see how our friends, the 4th year students and Ugandan friends from the hospital, teach and make the whole VHW program run. The classes were all really well taught, and it was cool to see how they taught medical concepts to people who don’t have any basic science foundational knowledge. Everything was extremely practical, and very relatable to real life situations that the VHWs experience all the time. It was a long and intense training day, from about 8-5. But even in just one day they covered so much material, with classes about patient interviewing/taking a patient history, mental illness, family planning, high blood pressure, and tuberculosis. I learned a lot from the classes too, so it was a pretty nice day. I have always loved going to school. But really the best part of the day was playing with babies again, particularly the 1 year-old son of one of the VHWs. We were already buddies from Monday when I first met him, Josephat, and his awesome mom, Dorothy. We also were together on Tuesday when I went for supervision in his village, so by the end of Friday after 3 days playing together this week we were totally best friends for life.

Saturday I went out to one of the villages to help with a health census. There isn’t too much to say about it because it was not super exciting. We went from home to home doing a comprehensive check of all of the health issues of everyone in each family. Everyone over 25 was screened for high blood pressure, and every child under 5 was screened for malnutrition. It was a long day, and no one was really available to translate for me, because everyone on the team was actively involved in the process itself, so I didn’t get to be extremely involved. It was really nice to be able to see many different homes and learn more about how people go about most aspects of their lives. It was interesting to me that a lot of people couldn’t say for sure exactly how old they are, and that most people have to walk 3 miles to get water. Just a couple of the simple things that are so unquestioned in our lives in the US and are totally different for people here.

The last question in the census set is about what health topics the family would like to learn more about from the VHW. I was really surprised and excited to see that every single household we interviewed wanted to learn about any and every health topic they could. I wish that our patients in the US were as interested and involved in their own health as people are here. They know much less on average than people in the US to start out with, but everyone I have met so far is so eager to learn and be able to better take care of themselves and their families. For the people out in these villages, the hospital is far away, medications may not be available or may be too expensive, and some treatments we really take for granted are just not present in Uganda at all. For example, the only option for cancer treatment here is surgical removal. If it’s not operable (and less things are operable here than are possible to operate on in the US), there is nothing at all that can be done. If someone needs heart surgery, they have to go to another country if they want to get it. Women want to deliver babies in the hospital because they know it’s safer, but some end up delivering on the side of the road because they didn’t start their 3-hour walk early enough. I think that these realities make people here more aware of the potential impact they can have on their own health, because the vast majority of the time they are the only ones who can manage their health.

I was kind of surprised to see that, even with far less resources, people here live very long lives where they are active and healthy to the end. I have met several people who are well into their 90’s who are still working in the fields all day. I think that the fact that they take responsibility for themselves so much more plays a role in this. I don’t know if there is a way to bring some of that spirit back to the US, but I am definitely more inspired than ever to try and get patients to invest in their own health and improve their knowledge of health-related issues.

My favorite part of Saturday was getting to Skype with some friends from Einstein. Although things are fantastic here and all the people are great, nothing compares to the kind of family we have there. I am truly blessed to be part of the AECOM Class of 2017.

Since we have the day off on Sundays, we decided to do a different hike this week that we traveled to. It was a beautiful sunny morning, so we were really excited when we headed out. The hike was really cool, it started in a bamboo swamp, and then as we moved up we entered the rainforest canopy. Unfortunately, by the time we got higher up it had become cloudy and cool again so most of the animals hid from us. But the view from the top was still really awesome. We could only see 4 of the 6 lakes that are technically visible from there because of the clouds and mist, but it was still pretty great. Pictures of that to come soon too.

Things are definitely picking up in terms of activity and work here, so sorry for the slight delay in the update. I’ll try to stay on top of things so I write once a week, but I may slip a little here and there. Overall, life here is great. I am learning a lot every day, and I am so happy I decided to spend my summer this way.

Week Three in Uganda

That’s good morning in the language here. I’m getting spelling now, really making progress. It’s been another amazing week, including an incredible adventure climbing a volcano and meeting gorillas! But we’ll get to that later. It is generally best to begin at the beginning, and I also like to save the best for last.

So this week started with our first big nutrition screening day on Monday. This is one of our most important projects, and something that we are almost entirely in charge of on our own. We are going into villages in the Kisoro sub-county of Nyuarusiza to identify children with malnutrition so that we can hopefully start a nutrition program there like we already have in the sub-county of Maramba. This program provides children who are malnourished with regular nutritional supplements and follow-up in addition to counseling for the family on how to provide proper nutrition. In order to make this happen, we have to go to all of the villages and screen all of the children under 5 years old. This involves measuring the mid-upper arm circumference (MUAC, a standard measure of malnutrition) and weight for every child and talking to the parents about their past nutrition history. It is a pretty large project, but we can screen a huge number of children in one day when everything is working properly. It didn’t exactly work out that way on Monday, because there was some miscommunication. We were missing a translator, so we could only go to two sites instead of three. And the VHWs didn’t totally understand what we were trying to do, so they tried to screen kids ahead of time and only bring us kids they already thought were malnourished. So when we got there they only had two kids ready to go. But it ended up being ok, we went from house to house and screened as many kids that way as we could, and still saw about 60 kids. I didn’t anticipate how hard it was going to be. Measuring MUAC is just putting a measuring tape around their arm and weighing is a scale with a hook that you hang a kind of pair of pants/diaper-looking thing that is most reminiscent of a baby swing from and put the child in it. Neither of these processes is painful or even uncomfortable, and if I could fit in the weighing thing I would hop right in because it looks pretty fun. But some of these kids scream like we are cutting off limbs. I have been toying with the idea of working in some kind of pediatric field, but this has made me question that a little bit. That’s mostly my eardrums talking, especially since I also had a screening day today. I can’t speak for sure about the nutrition status of a lot of kids or the rest of their health, but their lungs function spectacularly.

As always, Monday is market day and is therefore a great day. We all went down to the market together with the 4th year girls too, and I ended up getting a few more pieces of fabric to get more clothes made. I decided to try something crazy and gave Mama Beatrice (the lovely woman who makes clothes) a pair of my shorts to copy so that I’ll end up with some crazy patterned shorts. I also got a shirt and a skirt, went a little bit overboard. I am really excited to see how things come out this week when we go pick everything up.

Tuesday was one of the most significant days of my trip so far. Liz and I went out with one of the 4thyear girls, Elena, and the Family Planning outreach team, who was also working alongside a family planning NGO called Marie Stopes. We all went to a big health center in a sub-county called Busanza, and we had a really mind-blowing day. We got there ahead of the Marie Stopes team, so we had some time just hanging around (kind of the story of life in Uganda). That was pretty great though, because we taught all the kids who were gathered around staring at us how to play “duck, duck, goose.” We modified it a little to be “cow, cow, goat” because those are animals that they actually have here. I have never seen such a simple game get such a huge spectatorship before. After just a few minutes there were at least 40 kids playing and a group of at least 75 kids and adults watching. It was an absolute blast. The greatest way to start a day for sure. Once the team got there though, things started rolling fast. There were educational sessions about family planning, cervical cancer screening, and HIV, and there further breakout sessions about the details of each topic for anyone who wanted to receive services related to any of those things. At the same time that we were there, there was another group performing circumcisions on teenagers and young boys because studies have shown that circumcision helps decrease the transmission of HIV. It was an exceptionally busy place with so much going on, and we were fortunate to be able to see a little bit of everything.

The first thing that Liz and I saw was a tubal ligation by the Marie Stopes team. I have never seen a surgical procedure in the US, but I am guessing it goes a bit differently. The procedures happened in a side room, the size of a small exam room in a doctor’s office in the US. The patients only had local anesthesia, and the doctor and nurse wore gloves and aprons over their tshirts. The tubal ligation happened through one small incision in the abdomen, and then involved a lot of fishing around with a hook to find the fallopian tubes... I had expected the differences in technology, but I had not been prepared for the difference in attitude toward patients. I have not found that to be the case everywhere I go here, but I have noticed a difference in the kind of relationships between doctors and patients. I like the way that we try to make things about a partnership at Einstein, and that we do our best to ensure that patients understand everything that is going on and that they have their concerns and questions addressed. Things are a lot more authoritarian here, and people rarely know what disease they are even being treated for, but usually, care is given well and kindly.

Things improved from there. Liz and I went over to see our own team doing cervical cancer screenings and IUD insertions. We got to observe a few patients, and then Liz and I both got to perform one cervical cancer screening. It was really awesome, and it was nice to remember why we’re going to school for such a long time. One day, it’s going to be worth it to be able to help people like this. After that we also got to see the placement of birth control implants, that are injected into the upper arm and last for 3 years or 5 years depending on the implant chosen. They are very popular for women here, so it was good to understand that better. The last thing that we saw was the circumcision room. There were five tables and five boys all being circumcised at the same time. It was way too overwhelming for me, and so I didn’t stay in there for very long. I understand that it’s important for public health and Uganda as a whole as they work to combat HIV, but I feel like they could do it differently. I’m glad I experienced everything that the day had to offer though, and I definitely learned a lot. We got home pretty late, but it was ok because we went out to dinner with our Ugandan friends and didn’t have to cook.

On Wednesday I was sad because our focus group got canceled. That was sort of alright because I got a lot of work done, but it was frustrating because we traveled all the way out to our village (not a short or easy journey) before anyone told us that the group wasn’t happening. It ended up alright though, I got to exercise a bit and accomplish a lot. In the evening we celebrated Elena’s birthday by decorating the whole yard and making a cake and sangria. She was really surprised when she came home and saw everything decorated, and it was a really nice night enjoying time all together.

On Thursday we all shadowed in the chronic care clinic (CCC) at the hospital, which was a great experience. Patients who have chronic diseases come once a month to get checked on and have their medications refilled. I shadowed with Emma, and it was wonderful. Pretty similar to shadowing in a clinic at home, just a little bit more difficult when someone needed to be admitted to the hospital or if a certain medication ran out. We are going to start shadowing there regularly soon, so I am pretty excited about that. Friday was also a nice day, I went out with Jerome to some of the most beautiful villages I have seen so far. Every day is an adventure here, and I feel so lucky to be able to experience it all. On Friday night we went out to dinner and met a British law student who happened to be visiting Kisoro. He was really friendly and fun, so we invited him to come to dinner at our house on Saturday before he headed back to his summer internship job in Kampala.

Saturday my work ended up being canceled again, so I did more work at home until the afternoon when we started making dinner. We made a kind of jambalaya, and Liz created an oven on the stovetop, so we baked banana bread. We also made guacamole and our own hummus, so we basically had a feast. It was great. After our British friend left, it was time for bed because we had a big day on Sunday. That big volcano I talk about? We went to go climb it. We left home at 6:15 in the morning. As much as we tried to prepare, there was no way to really prepare for what we faced. It took us five hours to reach the top, a summit of 4,137 m (13,500 ft). We were literally above the clouds. I have never seen anything so amazing or so beautiful. The volcano is dormant, and so the top is a giant crater with a lake. We could see exceptionally far, across Uganda and Rwanda. I am putting loads of pictures on facebook, so try to check them out. There is no way I can even begin to convey how incredible it was. The pictures don’t do it justice either, but they come a lot closer. The way down took a lot longer because we were tired, hurting, and I twisted my ankle a little bit. But we got really lucky that the mountain gorillas happened to be nesting when we were reaching their level, and our guides let us go see them. They were gorgeous. And we got extremely close to them. They are so human-looking. We sat and stared at one of the males for ages, and he just stared right back. I was surprised at how comfortable and welcoming he seemed, but I guess they are used to people coming and staring at them by now. Suffice to say, it was an unbelievable day.

This week so far has been good, we are heading into a nutrition-heavy rest of the trip so it’s basically screening days and follow-up surveys all the time. It’s going well though, we saw over a hundred kids each day in each village for the past two days. I am really excited about being able to bring such important services to families who really need them. I know the rest of the trip will be busier than ever, but I cannot wait for everything that is coming. Next weekend we are going on safari in Queen Elizabeth National Park, so the next email will definitely be late. But it will have a lot more awesome stories for sure.

I miss the USA sometimes, mostly just you wonderful people though. And ice cream. I could really use some ice cream. I hope all is well back home! Do the 4th of July extra big for me!!!

June 21, 2014

This is Hannah writing from Kisoro, Uganda! I've been here for two weeks, and finally feel like I have a good enough understanding of the program here to write a little bit about it. It's been very exciting working here so far, and an amazing learning experience. Our biggest role (myself and the other MSII's, Cynthia and Liz) has been to help out with the Village Health Worker (VHW) program. So far I've found this program to be really incredible. Basically one or two people are selected from every village and trained with basic primary care skills to deliver health care to their communities. So far I've been to some of the villages to meet the VHW's, I've helped in the chronic disease clinic at Kisoro District Hospital (KDH), and yesterday we were able to sit in on a training session given to the new batch of VHW's at KDH. Today I traveled to one of the villages to help supervise a VHW, so I was able to understand his day-to-day responsibilities. Each VHW is responsible for identifying patients with acute illnesses (malaria, pneumonia, etc.) and referring them to KDH for treatment, and then following up on them after they are discharged. They are also responsible for identifying new chronic disease patients and checking up on older ones to make sure they are receiving and taking their medications. These medications are usually delivered through a program called CDCom (Chronic disease in the community), where a van drives around to villages and VHW supervisors, along with VHW's, deliver medications to chronic disease patients. The most common diseases I've seen so far have been pretty similar to those in the Bronx, such as hypertension, asthma, epilepsy and diabetes. One surprise on these visits has been seeing a few young patients with heart failure, probably as a result of rheumatic heart disease. On CDCom visits we take the BP and HR of every patient. I've been a little surprised at the number of patients with hypertension and diabetes, I didn't expect there to be so many. On Thursday at the clinic we had a woman with a BP of 225/120 (!) Overall I've been very impressed at the amount of monitoring and follow-up care given to chronic disease patients. The patients who don't show up to their appointments are promptly visited to see why they didn't show up and to make sure they have their medications. It's a lot of effort to visit every patient with a missed appointment at their home, but I think it really shows that the health care workers care about their patients in a more personalized way. I had one day of accompanying a supervisor on follow-up and it was a really cool experience riding through the mountains on a motorcycle to visit patients at their homes. Mostly (from the few patients I saw) the reason that they missed appointments has been that they were able to get their medicines at a different health center, but this isn't always the case, and I think the follow-up component is really important to make sure chronic disease patients don't slip through the cracks. I also saw a few patients with TB, which is something I haven't seen yet in the Bronx. Yesterday at the VHW training, there was a session on chronic diseases, and Wanda (an MS4) brought in a patient with diabetes for the VHW's to interview (reminded me of ICM!). They learned some basically interview questions the same way that we learned them at Einstein, such as asking the patient about her symptoms, her medications and so on.

Another amazing thing about the VHW program is that it is so comprehensive. For example, the VHW's are trained in domestic violence counseling, and are supposed to identify and counsel victims of domestic violence every month in their villages. They're also supposed to identify children with disabilities, and women to counsel about family planning and refer to the health clinic. In addition, they are supposed to identify all the pregnant women in their villages and counsel them on antenatal care and the importance of delivering in a health center or hospital. In fact, the VHW's get paid a bonus for every women they counsel who delivers their child at a health center. They are also supposed to identify children at risk of malnutrition and refer them to the hospital or enroll them in KDH's nutrition program. This is one of our projects for the summer, on Monday we're going to four villages to take MUAC's (middle upper arm circumference) on children with possible malnutrition, and get children enrolled in the nutrition program. This has been an interesting experience for me because I haven't seen many malnourished children in the US. The children qualify as moderately malnourished with a MUAC between 11.5 and 12.5 cm, and severely malnourished with a MUAC less than 11.5. So far I've gotten to take weights and MUAC's on some children, for the weight we bring a hanging scale that we just have to find a tree branch to hang it on, and then there is a seat attached that the child sits in to get weighed.

The VHW's are also trained about the importance of mental health and how to identify mental health patients in their villages. I've probably forgotten a few other aspects of the program, but I'm sure you can tell by what I've written how great and comprehensive it is. It's like having a primary care provider for every village, who makes home visits and can even give out some basic medications, and are trained about when to refer patients to the hospital. I also think it's great the the VHW's receive an incentive (a small amount of money) for every patient they refer to the hospital, and every malnourished child, pregnant woman, domestic violence victim, person for family planning or chronic disease patient they identify and counsel. (I'm probably forgetting a few other incentives). I think this is such a great way to encourage the VHW's to go out in the community and help the villagers. They're also encouraged to makes sure all young children receive proper immunization. I think it's also important that the VHW is usually nominated by their own village to become a VHW, which infers that they are usually a respected member of the community.

I also forgot to mention that the hospital care is
free, including medications, (I’m not sure that everything is free, I’ll have
to double check what is and what isn’t), but there is also an insurance program
called TPHP that gives extra benefits to members, including transport to the
hospital. This is a much needed service because many villages are very far away from KDH.

One other project that we MSII's are involved in has been leading focus groups, which has been really interesting so far. We go to the same villages every week and help write and facilitate a session along with some of the KDH staff, who translate for us and mostly lead the session. Our first session was about stress and second one was about family planning. The common methods of family planning used by villagers here are the implant (goes into the upper arm, lasts about 3 years) and Depo injection (lasts 3 months). Condoms are rare here in the villages, but I think more commonly used in cities like Kampala. I've learned a lot of interesting things from the focus groups, especially about the different perspectives of men and women here. This is going to be the subject of an entire paper at the end of the summer so I won't go into too much detail here.

Kisoro is a really beautiful place and it's been fun exploring so far! Last weekend I hiked to a nearby lake and tomorrow we're going on a hike through a bamboo forest. We're doing a safari at Queen Elizabeth park in two weeks, and will hopefully do some bigger hikes and will maybe see some gorillas before we go! Kisoro has market day every Monday and Thursday, where people brings in their crops to sell, and I've really enjoyed going to the market and trying new foods. That's it for now!I'll update soon about the nutrition project and hopefully some women's health shadowing and other projects!